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jOUfACll 

OF THE 

TENNESSEE MEDICAL 
ASSOCIATION 

JANUARY, 1973 

Vol. 66 No. 1 

Published Monthly By 
Tennessee Medical Association 
Office of Publication, 
112 Louise Avenue 
Nashville, Tenn. 37203 

Second Class Postage Paid at 
Nashville, Tenn. 

TMA OFFICERS 
President 

Wm. T. Satterfield, Sr., M.D. 

1188 Minna Place 
Memphis 38104 

President-Elect 
0. Morse Kochtitzky, M.D. 
2104 West End Ave. 
Nashville 37203 

Chairman, Board of Trustees 
C. Gordon Peerman, Jr., M.D. 
21st & Hayes Medical Bldg. 

Nashville 37203 

EDITORIAL STAFF 
Editor 

John B. Thomison, M.D. 

Managing Editor and 
Business Manager 
Jack E. Ballentine 

TMA EXECUTIVE STAFF 

Executive Director 

Jack E. Ballentine 

Assistant Executive Director 
L. Hadley Williams 

Executive Assistant 
John M. Westenberger 

Executive Assistant 
William V. Wallace 


conleni/ 

SCIENTIFIC SECTION 

21 Medicine Without an Ethic, Reverend Charles Carroll 

28 Reach to Recovery: A Postmastectomy Rehabilitation Program, John 
L. Sawyers, M.D. 

30 The Treatment of Status Convulsivus and Epilepticus in Children, 

Harold Cayce Waldrep, M.D. and J. T. Gabbour, M.D. 

34 Staff Conference 

38 From the Tennessee Department of Mental Health 

39 From the Regional Medical Programs 

40 Self-Evaluation Quiz 
43 EKG of the Month 

NEWS AND ORGANIZATIONAL SECTION 

55 President’s Page 

56 Editorials 

59 In Memoriam 

59 New Members 

60 National News 

62 Medical News in Tennessee 

63 Personal News 
65 Book Reviews 
67 Announcements 
74 Special Item 

91 Placement Service 

Contents listed in CURRENT CONTENTS/CLINICAL PRACTICE 
of The Institute for Scientific Information 


The Journal of the Tennessee 
Medical Association 
112 Louise Ave. 
Nashville, Tennessee 37203 

Published monthly under the direction of 
the Board of Trustees for and by members 
of The Tennessee Medical Association, a 
nonprofit organization, with a definite 
membership for scientific and educational 

purposes. 

Subscription $9.00 per year to non- 
members; single copy, 75 cents. Payment 
of Tennessee Medical Association 
membership dues includes the subscription 
price of this Journal. 
Devoted to the interests of the medical 
profession of Tennessee. This association 
does not officially endorse opinions 
presented in different papers published 
herein. Copyright, 1973 by the Journal of 
the Tennessee Medical Association. 
Advertisers must conform to policies and 
regulations established by the Board of 
Trustees of the 
Tennessee Medical Association. 


INSTRUCTIONS TO CONTRIBUTORS 

Manuscripts submitted for consideration for publication in the JOURNAL 
OF THE TENNESSEE MEDICAL ASSOCIATION should be addressed to 
the Editor, John B. Thomison, M.D., P.O. Box 70, Nashville, Tennessee 
37202. 

Manuscripts must be typewritten on one side of letterweight paper. 
Either double or triple spacing and wide margins must be provided to 
facilitate editing which will be legible for the printer. The pages should 
be numbered and clipped or stapled together, but they should not be 
placed in a binder. 

Bibliographic references should not exceed twenty in number docu- 
menting key publications. They should appear at the end of the paper. 
The bibliographic references must conform to the style used in the 
American Medical Association publications, as, — Alais, FG: What is Known 
About it, J. Tennessee M. A., 35:132, 1950. 

Illustrations should be numbered and identified with the author’s name. 
The editor will determine the number, if any, of illustrations to be used 
with the Journal assuming the cost of engravings and cuts up to $25. 
Engraving cost for illustrations in excess of $25 will be billed to the 
author. They will not be returned unless specifically requested. 

If reprints are wanted, the desired number should be indicated in the 
letter accompanying the manuscript. No reprints are provided free and 
a reprint cost schedule will be forwarded upon request. 


joumol 

OF THE TENNESSEE MEDICAL ASSOCIATION 

OWNED AND PUBLISHED BY THE ASSOCIATION 

JANUARY, 1973 
VOLUME 66, NO. 1 


Medicine 
Without an Ethic^ 

REVEREND CHARLES CARROLLt 

If medicine has not already, it will soon 
find itself defenseless — without an ethic. When 
the California Medical Association pronounces 
the erosion of the old ethic; when it claims that 
medicine has changed the law, public opinion 
and the church rather than been changed by 
them; when it insists that the time has come 
to place a relative value on human life; and 
finally when it pretends that medicine alone 
has the knowledge of human nature and human 
behavior to devise the new ethic, I think it time 
that that sweeping claim be challenged and that 
we ask what is happening to us — all of us. 

Let us begin at the beginning and review what 
happened in the abortion debate. 

When I returned to California in 1966 after 
a year in Berlin, friends approached me and 
asked for my views. At the time, I had not 
yet read the proposals before the legislature in 
Sacramento. Before expressing myself, I thought 
it best to study them. They called for abortion 
on five grounds; incest, rape, potential defor- 
mity, threat to the mental health, and threat to 
the physical health of the mother. At first blush, 
they made eminent good sense. 

Then surely I would have appeared to be 
a man without compassion had I opposed abor- 
tion in the case of incest. It was only as the 
months wore on that I asked myself when, if 
ever, two parties to an incestuous relationship 
would seek an abortion on this ground — at risk 
of the attendant publicity. 

*Presented at the 92nd Annual Meeting of the 
Louisiana State Medical Society, May 1, 1972, New 
Orleans. 

tPriest, Episcopal Diocese of California; Fellow, 
Institute for Ecumenical and Cultural Research at St. 
John’s Abbey and University of Collegeville, Minn. 


And no less surely I would have appeared 
to be without any genuine concern for others 
had I opposed abortion in the event of rape. 
Still, I asked why there had been no distinction 
made between statutory and criminal rape; why 
a woman who had been the victim of criminal 
assault would not seek immediate medical care; 
why rape would be given as grounds for an 
abortion a week or a month after it had oc- 
curred. 

Nothing troubled me quite as much, how- 
ever, as the proposal that the right to abortion 
be granted on ground of potential deformity of 
the fetus. In reading that, the memories of a 
lifetime returned, particularly those of the Ger- 
man doctors’ trial before the American Military 
Tribunal in Nuremberg in the late spring and 
summer of 1947. 

It was then that I realized that incest and 
rape had been introduced into the discussion 
more because of their emotional value in debate. 
It was then — again mindful of how slowly but 
inexorably a people can move from feticide to 
infanticide to homicide — that I asked myself, 
“What, in speaking of the potentially deformed, 
are we saying to and about those who are de- 
formed after birth? What are we saying to and 
about the totally disabled victims of automobile 
and industrial accidents? What are we saying to 
and about the totally disabled veterans of our 
wars?” 

During a visit to the Neurosurgical Rehabili- 
tation Center of the University of Wisconsin 
four years ago, I met a simply beautiful girl in 
her early 20s who was quadraplegic and preg- 
nant. Because the director of the center was 
a friend, I asked if he would be good enough 
to tell me something about her. He said that 
she had been in an accident; that she had been 
paralyzed; that she had met a handsome young 
man some months later who asked her to marry 
him; that he had overcome her misgivings, she 
had agreed and they had been married. He 
then told me of a question asked her by one of 


JANUARY, 1973 


21 


ihe interns on rounds that morning. 

“Enjoy your sex life?” 

“No” she replied. “J lost all sensitivity in 
that area of my body as a result of the accident. 
But my husband enjoys sex. We want a family. 
I am pregnant. And so, 1 have come here 
to learn how 1 might care for our child.” 

You who are doctors know how often we 
have sent our loved ones off to war or off on 
a trip with good food and good wine; and you, 
more than most men, know how indifferent and 
calloused we can become in our attitudes in our 
brief and infrequent visits to even the most 
committed and sensitive when they are totally 
disabled. 

If we are to allow potential deformity of 
the fetus as ground for an abortion, what are 
we saying to and about the irreversibly men- 
tally ill? One of the ugliest chapters in German 
medical history; one which pales only in com- 
parison to the extermination of the 6,000,000 
Jews in the gas ovens of the Third Reich was 
written by German psychiatrists who, in German 
mental hospitals, liquidated 240,000 of their 
300,000 German patients in specially contructed 
carbon monoxide chambers during the years of 
World War II. Deformity can mean many 
things. Early in the Nazi period, it meant 
“Jewish,” later it came to mean other things. 
But as Hermann Goering could say, “Who is 
a Jew is for me to decide.” When he needed 
a Jewish intellectual, he would want, (and 
later, unwant) him — without need of law or 
definitions. Where there is no ethic, there is 
only one law — that of power — naked, brutal, 
ruthless power. 

Threat to the mental health of the mother 
was advanced as a ground for abortion though 
mental health was not dehned. As one of 
the psychiatrists at the University of California 
Medical Center in San Francisco said to me 
shortly before I left last year, “Charles, where 
are we headed? What are we doing? My pro- 
fession had best look to its own reputation. 
There were times not long ago when I would 
have authorized an abortion, for example, in a 
case of manic depressive psychosis. We have 
moved far beyond that. We are granting abor- 
tions upon request to the denigration of psy- 
chiatry and our own good name.” 

Threat to the physical health of the mother 
was also advanced as a ground. And this, at a 
time, when medicine had scored as great and 

22 


significant advances as any in its long history 
and when such threats were minimal. More- 
over, no state would have denied the physician 
the right to perform an abortion if he were 
faced with the terrible choice of taking one life 
in order to save the other. 

What has caused me the greatest concern, 
however, is not the almost complete acceptance 
of these proposals in California. Then, the 
potential deformity provision was deleted. It 
was rather the editorial which appeared in 
California Medicine in September, 1970, to 
which I have already alluded. 

The first of many “eye-openers,” this ap- 
peared in the official Journal of the California 
Medical Association. It not alone claimed the 
right to formulate the new ethic to which we 
would all be asked to submit. It claimed that 
right for the community of medicine alone. It 
insisted that this ethic should be based on the 
scientific method and that it should be de- 
vised by scientists and scientists alone. At that 
point, I began to see ever more clearly how 
much this claim was merely an echo of a far 
more profound and sophisticated argument 
which even then was reverberating throughout 
the worldwide community of the life sciences. 

Konrad Lorenz, the Viennese zoologist, in 
his book On Aggression, had made precisely 
the same demand, calling for a new and be- 
coming humility from all disciplines other than 
his own. And he, who spent the better part of 
his life in Central Europe, did this in writing 
on aggression (the book’s original title being 
Das So-Gennante Boese: Ziir Naturgeschicte der 
Aggression or So-Called Evil: Concerning the 
Natural History of Aggression), mentioning 
Alexander and Caesar; yet never in 300 pages 
mentioning Lidice or Oradour, Auschwitz or 
Dachau, Himler or Hitler. 

More recently, Jacques Monod, a biologist 
and Nobel Laureate from France made much 
the same claim. In his book. Chance and 
Necessity, he called Jew and Greek, Christian 
and Marxist, in short, all of those who stood 
in the millenia — old Western tradition-animists. 
Discounting all of the contributions made by 
the humanities in the past and coming as close 
as any man in the scientific community to em- 
bracing a doctrine of absolute biological de- 
terminism, he, too, has insisted that science 
and science alone has the right to determine 
man’s future. 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Amidst all of these calls for sweeping change, 
it is interesting to note that some Germans 
have not yet forgotten the recent past. They 
have learned the high price that is inevitably 
paid when human life is denigrated and the 
individual’s claim to membership in the hu- 
mamim is subject to periodic review by a whim- 
sical authority. When the German Democratic 
Republic, early this year, legalized and offered 
to subsidize abortion, the Lutheran and Catholic 
bishops stood as one in opposition. Now, in the 
Federal Republic where a similar measure is 
before the Bundestag, the Catholic and Lutheran 
bishops have again taken their stand together. 

Not all Germans need to be reminded, as 
William L. Shirer reminds the readers of The 
Rise and Fall of the Third Reich, of the wisdom 
of George Santayana; “Those who do not re- 
member the past are condemned to relive it.” 
To those who have remembered and do re- 
member our debt is incalculable. 

In reading a series of essays published last 
year in Munich by some of the most eminent 
physical scientists, life scientists, lawyers, phi- 
losophers and theologians of Germany and 
Switzerland (a collection which I trust will 
soon be translated into English) I, for one, 
became still more keenly sensitized to the de- 
bate on human values, provoked by the abor- 
tion controversy. In this anthology entitled 
Menschenzuechtung: Das Problem der gen- 
etischen Manipidierimg des Menschen, (Human 
Breeding: The Problem of the Genetic Manipu- 
lation of Man), mention was made of Gordon 
Rattray Taylor’s The Biological Time Bomb 
not once but many times. Sensitive to his 
words and their meanings, they captured the 
full impact of what he had written much of 
which had been lost upon me. A scientific 
journalist, he wrote of the prospects of genetic 
engineering, the possibility of test tube babies, 
and the likelihood of defective embryos ap- 
pearing in the first stages of experimentation. 
Then he declared: “The necessity of destroying 
the defective embyro which constitutes abortion 
under present laws in many countries, will no 
doubt arouse resistance. Those countries who 
do not consider destruction of the embryo to 
be abortion until after the fifth month of preg- 
nancy, or some other stated period, will, there- 
fore, be at an advantage.” (p. 183) 

It was not lost upon the Germans that these 
words precede Taylor’s subchapter on “The 


Spectre of Gene Warfare” — not nuclear, not 
chemical, not biological, but gene warfare. 

In a world in which man is made for science 
rather than science made for man, those who 
seek abortion on demand of the woman — in- 
deed, all of us — had best ask ourselves if 
abortion on demand of the state and sterilization 
on demand of the state and euthanasia on 
demand of the state can be far away. In a 
world in which men and women are being 
manipulated by fears of a population explosion 
and a genetic apocalypse, there has been much 
concern for Spaceship Earth, but little for the 
crew. 

Within the American scientific community, 
these fears have no more articulate spokesman 
than Garrett Hardin, professor of biology at 
the University of California at Santa Barbara, 
and former president of the American Academy 
for the Advancement of Science. 

Let us examine what he has written and 
said over the last four years. In Science on 
December 13, 1968, he wrote on “The Tragedy 
of the Commons.” Comparing the loss of the 
public grazing lands in England (because of 
population increase) to the loss of the wide 
open spaces in the American West (because of 
its exploration, settlement and increased use), 
he sees the world suffering the same threat — 
overpopulation. 

Two years later, in the same magazine, on 
July 31, 1970, there appeared an editorial of 
which he was the author entitled “Parenthood: 
Right or Privilege?” In this, he made it un- 
mistakably clear that he considered parenthood 
a privilege granted by society rather than a 
right enjoyed by man. Eloquent testimony to 
the change which he himself had undergone — 
from statement of the problem to proposal for 
its solution — he left little doubt that manda- 
tory rather than voluntary controls would be 
needed. 

How ardently he espouses this cause is under- 
scored by Richard Neuhaus, former pastor of 
the Lutheran Church of St. John the Evangelist 
in Brooklyn, author of In Defense of People, 
recently published by Macmillan, Neuhaus 
writes of a symposium held in New York City 
in 1970. Hardin, one of the principal par- 
ticipants, poses the problem, as he sees it, in 
the form of a mathematical equation: “Popu- 
lation X Prosperity = Pollution.” Then, ac- 
cording to Neuhaus, Hardin adds: “To reduce 


JANUARY, 1973 


23 


pollution, one must reduce either population or 
prosperity, and it is better to reduce population 
rather than prosperity.” (p.l86) 

All this happened in the summer of 1970 
when the United States Bureau of the Census 
released a report which admitted that its 1967 
projection of the United States population in the 
year 2000 was an overestimate of 100,000,000 
(San Francisco Chronicle, August 13, 1970, p. 
1) and this — in the richest nation in the world 
which has some of the best, if not the best, 
computers and computer scientists in the world. 

On February 15 of this year, in Internal 
Medicine News, Hardin is reported to have gone 
even further. He not alone takes the view that 
voluntary population control is self defeating. 
He contends that “the desire and/or ability to 
use contraception effectively as a trait . . . will 
be perpetuated in the offspring who do so”: and 
he sees “the lack of this desire and/or ability 
perpetuating (itself) in the offspring of those 
who do not.” Surely, it would be difficult to 
find a more unequivocal statement of absolute 
biological determinism and/or a doctrine of 
man which represents a more radical reduction 
of man to a molecular system. Implying that 
the individual is genetically programmed to con- 
tracept or not to contracept by his forebearers, 
he believes that it is “poorer people, those who 
come from a long line of poor ancestors, and 
are apparently unable to better themselves who 
are least motivated to use contraception.” One 
of the rationales for mandatory controls, ap- 
parently, would be the presence of genes within 
certain groups in the population that were 
adapted to the “culture of poverty.” 

If anyone can believe that the “new ethic” 
will be without its political, economic and social 
implications, let him think on these things. There 
could be no more dramatic portrayal of the 
interrelationship of each and every problem 
and issue now encountered by the life sciences 
and the community of medicine. 

Let us take two — abortion and sterilization. 
Today, doctors are doing two things, only one 
of which they did before. Loyal to the Hippo- 
cratic Oath, the Nuremberg Code or the Helsinki 
Declaration, they, in times past, often agreed 
not to do what a patient asked not be done. 
Then, a doctor on occasion, tells a woman pa- 
tient that the results of a biopsy are positive; 
that her breast tumor is malignant; that it may 
well have mestastasized. It is not unusual for 

24 


him to respect her decision when she refuses a 
mastectomy. Now, however, the doctor is doing 
what he is asked to do. And, given the temper 
of the times, and pressured by a society in 
which the legal has become moral, some are 
doing so in violation of their own ethics and 
their own consciences. Admittedly, we live in 
a period of change, in a revolutionary era. But 
what will happen to the doctor who bows to the 
mood of the moment when the state demands 
of him what his patient has demanded — and 
received? What will there then be to defend him 
— without an ethic? 

There is good reason to fear for the future 
of medicine in this country. It is one thing to 
pronounce the demise of the Judaeo-Christian 
ethic, as the California Medical Association has 
done. It is quite another to say that a new 
ethic is needed but not specify what that ethic 
should be. Order without freedom is tyranny. 
Freedom without order is chaos. If you have 
any doubts, read the history of Japan during 
the 20 years armistice (1919-1939), the history 
of Germany (1919-1933), the history of the 
French Republic (1919-1940). In the “no- 
man’s land” between the alleged death of the 
old ethic and the birth of the new, in a time with- 
out an ethic which is commonly held and com- 
monly honored, who speaks for medicine? The 
doctor? The patient? And by what ethic does 
doctor or patient defend himself? 

When we succumb to fear of a genetic apoc- 
alypse; when we decry the “pollution of the 
gene pool”; when we claim that amniocentesis 
is an infallible diagnostic tool; when we demand 
prenatal examination of the unborn, what is 
there to prevent abortion of the woman whether 
she wishes to be aborted or not? Can we not 
admit, if only to ourselves, that when we talk 
of such things and contemplate the ways and 
means by which we might “improve the gene 
pool,” we are talking about denying some the 
right to participate in the reproductive process 
and, if only by implication, we are talking about 
the “drafting” of others? 

When the physician, for example, agrees to 
sterilize every patient at his or her insistence, 
what is there to protect the physician or patient 
when it is the state that insists? 

Let us examine what has happened in our 
courts in the last 50 years. 

In 1927, in the case of Buck v. Bell (274 
U.S. 200, 47 S. Ct. 584, 71 L. Ed. 1000), 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Mr. Justice Oliver Wendell Holmes read the 
majority opinion of the United States Supreme 
Court. The court, having been petitioned for 
the right to sterilize a retardate in the Common- 
wealth of Virginia, granted the petition on 
eugenic grounds. Holmes’ words on that oc- 
casion — “Three generations of imbeciles are 
enough” — have not been forgotten. What has 
been forgotten, however, is that his interest in 
eugenics was inspired by his father; and his 
father’s knowledge of eugenics was gained in 
the last quarter of the last century. 

In 1962, in the case known as “In Re Nora 
Ann Simpson,” Judge Holland M. Gary of the 
Probate Court of Zanesville County, Ohio, de- 
cided to grant a mother the right to have her 
daughter sterilized. The daughter, who was a 
young, attractive retardate, had been impreg- 
nated and delivered and her child had been put 
up for adoption by a public welfare agency. 
The court, while citing Buck v. Bell, found still 
other— perhaps more important — grounds for 
sterilization. “To permit Nora Ann to have 
further children,” the judge declared, “would 
result in additional burdens upon the county and 
state welfare departments . . .” (180 North 
Eastern Reporter, 2d. Series 206). With that, 
cost benefit analysis by judicial authority entered 
the practice of medicine. 

Why do I fear this trend? Because I have 
heard men in California, men of high ideals 
and noble purpose, ask quite openly and with 
disarming honesty whether we have the right 
to maintain the thousands of retardates at 
Sonoma State Hospital — in view of the burden 
their care imposes upon the welfare budget of 
California. 

With this, the question before the house be- 
comes something quite other than it had been 
in the days when the Hippocratic Oath was 
honored. The question now is: “Who Is Hu- 
man?” When we start to count mouths on 
one hand and food supplies on the other, we 
will inevitably talk first of the quantity of life; 
then, of the quality of life. But who is to de- 
fine “quality?” Who is to have the power to 
declare the other “wanted” or “unwanted?” To 
what branch of government — executive, legis- 
lative or judicial — shall we entrust the power 
to define; to “want” and “unwant”? What 
branch shall develop policy? What branch shall 
implement that policy? What agencies shall en- 
force the laws? Are we moving inexorably 


toward that day when the individual’s claim to 
membership in the humanum is subject to peri- 
odic review and his ability to pass the test 
dependent upon his productive capacity and his 
value to society? By what standards does so- 
ciety judge an individual to be productive? By 
what value system does society accord his life 
value? 

When I contemplate the extremes to which 
some very sane men are willing to go to avoid 
a genetic apocalypse, I recall my meeting with 
a retired professor of zoology in Berkeley last 
year. A man of gentle mien who had taught for 
many years at one of the state colleges in Cali- 
fornia, he asked, “Would you approve the liqui- 
dation of all diabetics?” 

“Of course not,” 1 replied. 

“Neither would 1,” he continued, “but would 
you approve the sterilization of all diabetics?” 

“No,” 1 answered. 

“Then,” he declared, “prepare yourself for 
a world population that, within a hundred )^ears, 
could well be 50 percent to 60 percent diabetic.” 

I make no claims to expertise. But 1 do have 
some friends who are expert. When I returned 
to the University of California Medical Center, 
1 called upon one of them. Dr. Peter Forsham, 
an endocrinologist and head of the metabolic 
unit. 

“Peter,” I began, “you have had diabetes 
since your early teens. As a young man, you 
were doubtlessly told that you had a life expec- 
tancy of 40 years. You, as 1, are now 55. Is 
there any merit to the dire prediction made me 
by this zoologist?” 

“Charles,” he answered, “1 will tell you this. 
Within five years, 1 will be able to take the 
islet of Langerhans from the pancreas and trans- 
plant it to the kidney. Then the diabetic will 
again produce the insulin he needs.” 

“But,” I added, “you have not discussed 
the sperm count.” 

“For that,” he concluded with a wry smile, 
“I would ask ten more years.” 

It is not my intent to interpret Dr. Forsham’s 
words for others. They may be differently in- 
terpreted by different people. Still, I do not find 
him living in an Aristotelian or Newtonian uni- 
verse but rather an Einsteinian universe; his 
world, not one of Euclidean but rather Rieman- 
nian dimensions. Conscious of the finitude of 
man and conscious of finite man’s limitations 
within the space time continum, he has applied 


JANUARY, 1973 


25 


some of the insights of the physical sciences 
to his study of the life sciences. And appreci- 
ative of the hard-won insights of the humanities, 
he accepts the fallibility of all human prediction 
and concentrates upon the elimination of dis- 
ease rather than the sterilization of the disease 
bearer. 

Unhappily, however, the contrary assumption, 
the assumption of inerrancy is rather wide- 
spread. In The Atkmtic in May, 1971, Edward 
Grossman, a student of George Wald at Har- 
vard, wrote an article on “The Obsolescent 
Mother.” In reading it, 1 asked myself — with- 
out the slightest desire to be facetious — if the 
penis envy of the woman, so well described by 
Sigmund Freud, had not been succeeded by the 
womb envy of the man, for surely the genet- 
icist’s attempt to effect an absolute divorce 
between sexual enjoyment and sexual reproduc- 
tion through the production of life in vitro 
could minimize if not eliminate the role of 
woman from the reproductive process altogether. 

Grossman suggests and supports the devel- 
opment of an “efficient artificial womb” in the 
hope that, if it catches on culturally, “it will 
mean that the awe-fulness associated with preg- 
nancy and childbirth will have nothing to feed 
on, and motherhood, if it continues to excite 
any awe at all, will not do so more than father- 
hood.” Furthermore, he insists that the mother 
"will find that society does not expect her to 
have a special relation to her offspring” and 
that a “society that can grow fetuses in a 
laboratory will be more disposed to have mean- 
ingful day — and night — care centers and com- 
munal nurseries on a large scale for the state, 
being a third parent, will wish to provide for 
the maintenance and upbringing of its children.” 
Then, natural pregnancy may become an anach- 
ronism . . . The uterus will become appendix- 
like.” (pp. 48-49). 

Immediately following Grossman’s article in 
The Atlantic there was one by James D. Watson, 
professor of molecular biology at Harvard, a 
Nobel Laureate, and one of the co-discoverers 
of the genetic code, the secret of DNA. His 
was quite a different spirit. 

In posing the question: “Moving Toward 
The Clonal Man: Is That What We Want?” 
he undertakes a measured review of the ad- 
vantages and disadvantages of test tube con- 
ception. Then he makes this sober plea: “This 
is a matter far too important to be left solely 

26 


in the hands of the scientific and medical com- 
munities. The belief that surrogate mothers and 
clonal babies are inevitable because science al- 
ways moves forward, and an attitude expressed 
to me recently by a scientific colleague, represent 
a form of laissez-faire nonsense. . .” 

“I would thus hope” he concludes, “that over 
the next decade wide-reaching discussion would 
occur . . . about the manifold problems which 
are bound to arise if test tube conception be- 
comes a common occurrence . . . Admittedly 
the vast effort . . . will turn off some people — 
those who believe the matter is of marginal 
importance now, and that it is a red herring 
designed to take our minds off our callous atti- 
tudes toward war, poverty and racial prejudice. 
But if we do not think about it now, the possi- 
bility of our having a free choice will one day 
suddenly be gone.” (p. 53) 

TO SUM UP: Medicine without an ethic; the 
law without a norm; and the religious com- 
munity without a theology of life and death, 
man and nature; will leave people — without a 
defense. This is particularly true in a world in 
which so many are willing to sacrifice the other 
rather than sacrifice jor the other. 

For those in the community of medicine, the 
holocaust should provide sufficient warning. 
When Hitler came to power, the only oath that 
had been required of a German physician was 
one of loyalty to the Weimar Constitution. That 
was later supplanted by an oath of loyalty to 
Hitler alone. Without an ethic, German medi- 
cine was defenseless. 

For those in the community of law, the mo- 
tion picture, “Judgment of Nuremberg” should 
provide a caveat all its own. When, in the last 
moments of that film, the German Judge Jan- 
ning runs to his cell door and, grabbing the 
bars, shouts to his American colleague. Judge 
Haywood, “I did not know it would come to 
that. You must believe it. You must believe 
it.” Haywood first stares at him and then, al- 
most without thinking, he spoke to him as 
though he were speaking to a child, “Herr Jan- 
ning. It came to that the first time you sen- 
tenced to death a man you knew to be inno- 
cent.” {Judgment at Nuremberg by Abby Mann, 
p. 136). Without a norm, German law was 
defenseless, a mere tool of the tyrant’s will. 

For those in the community of religion; the 
words of Elie Wiesel in Night should provide a 
present day reminder of what happens to the 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


man who pronuonces God is dead. In this an 
account of his days at Auschwitz, he recounts 
the hanging by the SS of two adults and a 
child, the child “with the face of a sad angel.” 
The adults, he writes, died quickly, the weight 
of their bodies speeding their deaths. But the 
child? 

“For more than half an hour he stayed there, 
struggling between life and death, dying in slow 
agony under our eyes. And we had to look 
him full in the face. He was still alive when 
I passed in front of him. His tongue was still 
red, his eyes not yet glazed. 

“Behind me, I heard . . . 

“Where is God now?” 


“And 1 heard a voice within me answer him: 
“Where is He: Here He is — He is hanging 
here on this gallows.” (p. 76) 

Wiesel’s words are strangely reminiscent of 
another Jew who was crucified between two 
thieves. (Matthew 25:34-35). Without a theol- 
ogy that calls each man to see the Wholly 
Other in his neighbor, the German people — 
Jew and Christian, believer and unbeliever — 
were defenseless. 

This is the Truth that sets men free. It was 
then. It is now. 


Reprinted from The Journal of the Louisiana State 
Medical Society, Sept., 1972. 


(continued from page 44) 




.. ^ AO fnrApc; are ItdRIZONTfJL ; Counterclockr^i-ise loop at 20" 
FROsm. Clockwise loop . 0 . Iniclal lorces markedly slowed add anterior, 
markedly slowed and superior 


X,Y,2, LEADS: Sinus Eiiythm. 


RIGHT SAGGITAL: Slowed anterior— superior iaitii 
forces. T loop Inferior. ST foroes are siiehti’ 
inferior. 


Initial 


IMPRESS ION: .Accelerated AV coaductioa - Type A. 


Fig. 3 


JANUARY, 1973 


27 


Reach to Recovery: A 

Rehabilitation Program 

JOHN L. SAWYERS, M.D.* 



The Reach to Recovery Program of the 
American Cancer Society is a rehabilitation 
program for women who have had partial or 
complete breast amputation. The program is 
designed to meet their psychological, physical 
and cosmetic needs. It is estimated that one 
in 20 women over 40 years of age will develop 
cancer of the breast. At the present time in 
the United States over 500,000 women are 
living who have had a mastectomy for breast 
cancer. The operation does not impair the 
patient’s general health, but the emotional and 
physical impact can be temporarily devastating. 
The Reach to Recovery Program helps the pa- 
tient and her immediate family to see the oper- 
ation in its proper perspective and, in coopera- 
tion with the patient’s physician, to accomplish 
an effective, rapid rehabilitation following mas- 
tectomy. 

This program, originated by Mrs. Terese 
Lasser in 1953 with funds made available by 
her late husband, J. K. Lasser, started as The 
Reach to Recovery Foundation and has now 
become a rehabilitation program of the Ameri- 
can Cancer Society. The Reach to Recovery 
Program was introduced into Tennessee by the 
Nashville-Davidson County Unit of the Ameri- 
can Cancer Society in 1968 by Mrs. Dodie 
Allman, a registered nurse and former mastec- 
tomy patient, who initiated the program in the 
Nashville hospitals. It was immediately accepted 
with enthusiasm by surgeons and patients. With- 
in three years, programs had been activated in 
Memphis, Knoxville, Morristown, and Chatta- 
nooga. Volunteers are now available throughout 
the state. 

The Reach to Recovery Program enables the 
physician and surgeon to provide mastectomy 
patients with specialized assistance without cost 
and without interfering with the doctor-patient 
relationship. When permission is given by her 
doctor, the mastectomy patient is visited by an- 
other woman who has had the same operation. 


^Chairman, Professional Education Committee, Ten- 
nessee Division, American Cancer Society. 


The patient sees that it will be possible for her 
to look normal and to return to her usual 
activities. 

Only specially selected and trained volunteers 
may call upon mastectomy patients. These 
volunteers are former mastectomy patients who 
have demonstrated a desire to help other patients 
who have had similar surgical procedures. Be- 
cause of her personal experience and her suc- 
cessful adjustment, the volunteer is in an unique 
position to give the patient information about 
those things which the patient may hesitate to 
discuss with her physician — such as adjustments 
which can be made in clothing, names of bra 
fitters at department stores, and reaction of her 
husband and teenage children. 

When the volunteer visits a patient in the 
hospital, she provides a gift of a Reach to Re- 
covery kit. This kit contains a manual with in- 
formation for the patient and her family, a ball 
and rope for exercises and a temporary breast 
prosthesis for the patient to wear home when 
leaving the hospital. The volunteer, with per- 
mission of the patient’s surgeon, demonstrates 
and explains exercises to improve arm and 
shoulder motion. Suggestions are given for bra 
comfort and explanation of various breast forms 
as well as clothing adjustment. Where indicated, 
personal problems are discussed, but volunteers 
never answer medical questions or make com- 
parisons of operations. The volunteer leaves her 
phone number with the patient so that she may 
be contacted for further assistance if needed. 
The volunteer will accompany the patient for 
fitting with a regular prosthesis after the patient 
has been told by her doctor that she is ready. 
Clothing, particularly bathing suits, is discussed. 
No products are sponsored, nothing is ever 
sold to a patient, and patient names are kept 
confidential. 

Unlike the ostomy and laryngectomy rehabili- 
tation programs. Reach to Recovery is not a 
club. The woman is encouraged to return to her 
normal way of life as soon as possible. Mastec- 
tomy patients are assured that they are just as 
much a woman as ever. The volunteer offers 


28 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


living proof to the patient that she can return to 
a normal life. 

The main thrust of the program is aid to the 
patient, but benefits accrue to the surgeon and 
physician. Reach to Recovery offers a service 
which the busy, overworked physican may make 
available to his patients and which will save him 
time for himself and his staff. This assistance 
is provided without cost and without interfering 
with the doctor-patient relationship. 

The Reach to Recovery Program also edu- 
cates personnel responsible for the comfort of 
the mastectomy patient. Lectures and demon- 
strations are given to nursing students, medical 
students, social service workers, and other in- 
terested personnel. Volunteers have talked to 
graduate nurses for their in-service training and 
to hospital medical staff physicians. During 
these talks the Reach to Recovery volunteer 
demonstrates postmastectomy exercises, shows 
prostheses and how they are worn, and demon- 


strates clothing and cosmetic devices for dis- 
guising discolorations and scars. Most impor- 
tantly she instills into the audience an awareness 
of the patient’s reaction to her operation. 

The Reach to Recovery Program has proved 
its usefulness in rehabilitation of the mastectomy 
patient. It deserves the support of the medical 
profession. Surgeons should ask for Reach to 
Recovery volunteers to visit their postmastec- 
tomy patients in the hospital and should urge 
their well-adjusted, cured mastectomy patients to 
become volunteers. 

Additional information and literature on the 
Reach to Recovery Program in Tennessee may 
be obtained by calling or writing the American 
Cancer Society, Tennessee Division, 2519 White 
Avenue, Nashville, Tennessee 37204. Local 
unit offices of the American Cancer Society will 
also supply information regarding this rehabilita- 
tion program. 


SAINT 

ALBANS 

PSYCHIATRIC HOSPITAL 

Radford, Virginia 


STAFF: 

James P. King, M.D. 

William D. Keck, M.D. 

Morgan E. Scott, M.D. 

David S. Sprague, M.D. 

Edward E. Cale, M.D. 

Delano W. Bolter, M.D. 

Terkild 

VInding, M.D. 

Clinical Psychology: 
Thomas C. Camp, Ph.D. 
Carl McGraw, Ph.D. 

Don Phillips, Administrator 

George K. White 
Asst. Administrator 


JANUARY, 1973 


29 


The Treatment of Status Convulsivus 
And Epileptieus in Children ^ 

HAROLD CAYCE WALDREP, M.D., and J. T. JABBOUR, M.D. 


Convulsions are the most common sign of 
functional disturbance of the central nervous 
system. This is confirmed by the fact that more 
than eighty percent of convulsive disorders 
begin during the first decade and also because 
six percent of all children have a history of one 
or more convulsions. The convulsion in a child 
is both a frightening experience for the parents 
and a diagnostic and therapeutic challenge for 
the physician. It is well known that early con- 
trol of convulsions in childhood is vital in pre- 
venting residua, such as hemiplegia, recurrent 
convulsions, behavior disorders, or even death 
in children. 

Status epileptieus is a condition of repetitive, 
prolonged seizures, during which a state of un- 
consciousness persists between seizures. Status 
convulsivus is a condition of serial or repetitive 
seizures without altered consciousness. 


which is the primary cause of the seizure; 

2. Maintenance of an open airway with ade- 
quate pulmonary ventilation; 

3. Adequate oxygenation and maintenance of 
circulation; 

4. Prevention or reduction of cerebral edema; 
and, 

5. Prevention or reduction of complications, 
such as hyperpyrexia, dehydration, infec- 
tion, and electrolyte problems. 

The immediate and subsequent complica- 
tions of convulsions are shown in Table 1. 
These may give a clue to the problem of man- 
agement of acute convulsions. The increased 
neuronal activity from any cause, acquired or 
genetic, produces an abnormal epileptogenic dis- 
charge above the seizure threshold, resulting in 
seizures. This increased muscular and secretory 
gland activity causes accumulation of secretions 


TABLE 1 

COMPLICATIONS OF STATUS CONVULSIVUS AND TREATMENT 
Complication Treatment 


1. Pulmonary 


2. Hypotension 

3. Hyperpyrexia 


1 . Keep airway open 

2. Give oxygen if there are signs of cyanosis and hypoxia, (2-4 lit/min) 

1. Phenylephrine, 5 mg. IM, or 0.5 mg. IV, OR 

2. Methoxamine, 10-15 mg. IM or 5-10 mg. IV 

1. Alcohol and ice water sponge 

2. If seizures continue with hyperpyrexia, suggesting cerebral edema, hypothermia 
should be induced with dehydrating agents 

(a) Infuse mannitol solution in a dose of 2-4 gm./kg. at a rate of 60 drops/ 
minute. 

(b) Intermittent use of hypertonic glucose solution for cerebral edema, with 
maintenance of fluid intake by dextrose saline solution, is recommended 
in protracted seizures. 


The immediate problems encountered in the 
management of the child with convulsions in- 
clude : 

1. Control of the abnormal neuronal activity 


fFrom the Section of Pediatric Neurology, Univer- 
sity of Tennessee, LeBonheur Children’s Hospital, 848 
Adams, Memphis, Tenn. 38103. 

*A study performed while on the Pediatric Neu- 
rology Elective (HCW). 


and obstruction of the respiratory airway. In- 
creased muscular tone during this period also 
causes interference with cerebral blood flow and 
venous congestion, with the accumulation of 
metabolites which cause cerebral vasodilatation 
and a decrease in cerebral circulation, resulting 
in hypoxia and cerebral edema. The decrease 
in cerebral circulation with hypoxic cerebral 
damage may eventually result in cerebral throm- 


30 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


bosis and infarction, which lead to permanent 
residua. 

TYPES OF DRUGS 

The abnormal neuronal activity can be con- 
trolled by several different drugs which have 
anticonvulsive effects on the central nervous 
system. The depressant effects of the drugs are 
not without adverse and variable reactions. 
These should be familiar to the physician. The 
drugs available which have been in use in the 
treatment of convulsive disorders include the 
following: 

1. Anesthetics Inhaling Ether 

Halothane 

Intravenous Thiopentone 

Methohexitone 

2. Anticonvulsants Barbituric acid 

Derivatives 

Nembutal 

Seconal 

Amytal 

Phenobarbital 

Hydantoin 

Diphenylhydantoin 

(Dilantin) 

Diazepam 

Valium 

ANESTHESIA 

Ether has been used for many years as a safe 
inhaling anesthesia. To be effective as an anti- 
convulsant, surgical levels of anesthesia must be 
achieved. At this level, there is a depression 
of cortical activity and a reduction of conducted 
impulses. Side effects include irritation of the 
mueous membranes, coughing, vomiting, and 
transient hypertension. 

Halothane, one of the newer inhalant anes- 
thesias, is about five times as potent as ether. 
As with ether, it may be used as an anticon- 
vulsant if given to the extent of producing sur- 
gical anesthesia. This gas is not as irritating to 
the mueous membranes though respiratory 
depression and hypotension are major side ef- 
fects of Halothane induction if not properly 
administered. 

These two gases should be administered by 
those who are trained in the practice of admin- 
istering anesthesia. An anesthetic death result- 
ing from an attempt to treat status epilepticus 
can be avoided by using such personnel, pre- 
cautions, and equipment. 


ANTICONVULSANTS 

Valium (Diazepam): This is a benzodia- 

zepine derivative which is used for the treat- 
ment of anxiety and for skeletal muscle relaxa- 
tion. The major focus of central depressant 
aetion is on the spinal reflexes and the brain 
stem reticular system. Valium depresses the 
duration of electrical after-discharge in the lim- 
bic system, the amygdala, and the hippocampus. 
The metabolic rate has been studied and its 
action is of rapid onset and short duration. 
Following a single dose of the drug, a portion 
is rapidly excreted (half life of 7-10 hours), 
while the remaining portion is excreted slowly 
(2-8 days). It is absorbed, peaks, and is ex- 
creted at approximately the same rate by oral, 
intravenous, or intramuscular administration. 
Seventy percent of the metabolites are excreted 
in the urine. 

Barbiturates: Whereas the gases must be 

given to levels of surgical anesthesia to stop a 
convulsion, barbiturates act specifically as an 
anticonvulsant and therefore need not produce 
a state of sedation. Their action is not com- 
pletely understood. Generally, barbiturates ap- 
pear to have their greatest depressant action on 
the multineuronal systems, effectively blocking 
conduction through the reticular system; this 
results in suppression of cortical arousal, and 
barbiturates may act on the neuronal membrane 
in such a manner as to increase the membrane 
threshold to repetitive stimuli. 

Because phenobarbital is degraded by the 
liver and excreted by the kidney, it must be 
used cautiously in patients with either hepatic 
or renal dysfunction. Slow intravenous admin- 
istration is recommended to prevent acute 
cardiorespiratory depression. 

Paraldehyde: This is a safe drug for use as 
an anticonvulsant. Even at toxic levels there is 
no significant depression of the respiration and 
systemic circulation. Nevertheless, paraldehyde 
should be used cautiously in a dosage of 0.15 to 
0.3 ml/kg, IM or IV. Because it is highly ir- 
ritative and may cause muscular necrosis, a 
maximum dosage of 3 cc. is given at any one 
site. Approximately eighty percent of the drug 
is metabolized by the liver; therefore, it must 
be used cautiously in patients with hepatic 
disease. 

Dilantin (Diphenylhydantoin): Through an 

unknown action on the neuronal membrane, 
Dilantin inhibits the progressive spread of 
seizure discharges in the brain. This exogenous 


JANUARY, 1973 


31 


pharmacologic stability results in a reduction of 
neuronal irritability and activity. Although 
Dilantin suppresses the transcortical spread of 
electrical activity from one area to another, it 
does not prevent spread from the centren- 
cephalon, which is responsible for bilateral syn- 
chronous paroxysms. 

Dilantin has no sedative effects, except in 
large doses, and its side effects are used to 
determine therapeutic doses. They include 
nystagmus, ataxia, and lethargy. Gum hyper- 
plasia is common, but hematologic effects rarely 
occur. 

After the initial therapy has been started to 
control the seizure activity, the diagnostic eval- 
uation, noted in Table 2, is often helpful. 

The treatment of the acute convulsion varies 
with the various studies which have been re- 


ported in the literature. These findings are 
presented in Tables 3 and 4. 

TABLE 2 

DIAGNOSTIC EVALUATION 

1. Electrolytes, Ca, phosphorus, BUN, fasting blood 
sugar, sodium, potassium; 

2. Skull, sinus, and chest films, bone survey; 

3. Electroencephalogram; 

4. Cerebrospinal fluid studies; 

5. Toxicity studies (serum or urine); 

(a) thallium 

(b) lead 

6. Viral studies; 

(a) neurotropic battery 

(b) respiratory battery 

(c) Herpes simplex titers 

7. Brain scan and cerebral angiogram. 


TABLE 3 

THE EEEECTIVENESS OF VARIOUS DRUGS IN STATUS CONVULSIVUS 


Study 

Drug 

# Of Cases 

Effective Control 
of Seizures 

% Effective 

Sciarra 

Amytal IV 

1 

5 

71% 


Paraldehyde IV 

5 

3 

60% 


Ether 

5 

2 

40% 


Phenobarbital IV 

23' 

3 

13% 


Phenobarbital IM 

33 

4 

12% 

McGreal 

Paraldehyde 

16 

12 

75% 


Phenobarbital 

14 

8 

51% 


TABLE 4 

RECOMMENDATIONS OF SPECIFIC THERAPY FOR STATUS CONVULSIVUS 


Study 

Drug 

Recommendation 

Murphy & Schwab 

Dilantin 

100 mg./70 lbs. (3 mg./kg.) IV 

Berg & Yannet 

Phenobarbital 
Sodium rV 

To be given in any seizure lasting longer than twenty minutes. 
Initial dose of 4-7 mg./kg., with a half of the initial dose 
repeated at 20-30 minute intervals until a maximum of 15 
mg./kg. has been given. 

Chao 

Nembutal IV 
Phenobarbital 
Sodium IM 

Give Nembutal, 4-5 mg./kg. IV, and phenobarbital, 3-6 mg./ 
kg. IM simultaneously. (If the patient has respiratory or 
general depression complications, give paraldehyde, 0.3 cc./kg. 
IV instead of Nembutal.) 

Carter 

Phenobarbital 
Sodium IV 

Sixty to 100 mg. in infants under one year; 120-200 mg. for 
children between 2-5 years; up to 300 mg. for older children. 

Lombroso 

Valium IV 

2-5 to 10 mg. injected slowly over one to 10 minutes. 


32 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Condition 


HEALTH SCIENCES LIBRAf??fl 
TABLE 5 UNIVERSITY OF MARYLAN3! 

RECORDED TREATMENT OF STATUS CONVULSIVUS BALTIMORE 

Immediate Convulsive Therapy 


1. First seizure less than 
20 minutes 


2. (a) History of prolonged 

seizures (longer than 20 
minutes) or 
(b) Discontinuation of 
medication 


1. Valium, 0.5 mg. /kg. IV for immediate control. 

2. Phenobarbital, 4-7 mg./kg. IV. 

3. Paraldehyde, ql5 mins, IM, if the Valium and phenobarbital are in- 
effective. 

4. Maintenance control as needed. 

1. Valium, 0.5 mg./kg. IV for immediate control. 

2. Phenobarbital, 3-5 mg./kg. IV (should be diluted to about 2.5% so 
that have 10-25 mg. of barbiturate per cc.). Must be given slowly in 
order to avoid respiratory depression. 

3. Phenobarbital, 5-6 mg./kg. IM. 

4. ± (In case of respiratory depression, substitution of paraldehyde for 
barbiturate is indicated in a dilute solution of 20 cc. paraldehyde in 
200 cc. of normal saline, IV.) 

5. Maintenance control as needed. 


The choice of treatment of status epilepticus 
is as variable as the individual studies. The 
choice today utilizing several medications, but 
especially Valium, is summarized in Tables 5 
and 6. 

REFERENCES 

1. Carnegie, DM: The emergency treatment of the 
convulsing child with particular reference to general 
anesthesia. Develop Med Child Neurol 6:183, 1964. 

2. Gastaut, H, Poirer, F, Payan, H, Salamon, G, 
Toga, M, Vigouroux, M: HHE syndrome: Heniicon- 
vulsion, hemiplegia, epilepsy. Epilepsia 1:418, 1960. 

3. McGreal, DA: The emergency treatment of con- 
vulsion in childhood. Practitioner 181:719, 1958. 

4. Hunter, RA: Status epilepticus. History, inci- 

dence, and problems. Epilepsia (Boston) 1:162, 1959. 

5. Whitty, CWM, and Taylor, M: Treatment of 
status epilepticus. Lancet 2:591, 1949. 

6. Lombroso, CT: Treatment of status epilepticus 
with diazepam. Neurology (Minneapolis) 16(7) :629- 
634, 1966. 


TABLE 6 

TREATMENT OF STATUS EPILEPTICUS 


Supportive: (1) Maintain airway 

(2) Clear Secretions 

(3) Position to prevent aspiration 

(4) Start I.V. (preferably with 
intracatheter) 

Seizure: Valium, I.V. 


Cessation of 

Seizures: Phenobarbital, 5 mg./kg. /day 

1st dose I.M., then q6h 
Dilantin, 5-10 mg./kg. /day 
Vz of daily dose first 
I.V. slowly 

Seizures Recur: Intubate with respirator present 

Phenobarbital, I.V. until seizure stop 


Seizures Persist: General anesthesia, 1-2 hours (ether, 

cyclopropane) 




FAMILY PHYSICIANS. INTERNISTS. GEN- 
ERAL SURGEONS. ORTHOPEDIC SUR- 
GEONS. UROLOGISTS. OB-GYN. RADI- 
OLOGISTS. AND PATHOLOGISTS needed 
for various communities throughout Tennes- 
see. All opportunities are located in towns 
with a modern, fully-equipped, JCAH ap- 
proved hospital. Contact: E. J. Ryan. Jr.. 
Director-Medical Relations, Hospital Corpo- 
ration of America, P.O. Box 550, Nashville, 
Tennessee 37203. 


* 


Elegant Two Bedroom, Two Bath 
Apartment on one of the three lead- 
ing shelling beaches in the world. 
Large screen porch overlooking the 
Gulf of Mexico. Golf and Wildlife 
Sanctuary nearby. Minimum rental 
2 weeks. 

RALPH CALL 
Dept. 15A 
Sunset South 
Sanibel, Florida 33957 


JANUARY, 1973 


33 



/loff confeime 

?■ ' . - 


Vanderbilt University Hospital, Nashville* 
ENTEROCOLITIS IN AN INFANT 

DR. DAVID S. ZAMIEROWSKI— This female in- 
fant was first admitted to the Vanderbilt University 
Hospital at six weeks of age. She weighed 8 pounds 
2 ounces at birth and was the product of a full-term 
pregnancy. The mother had been well throughout the 
pregnancy except for persistent monilial vaginitis. 
Both the mother and the child were discharged from 
the hospital three days following delivery. The baby 
was started on breast feedings and was begun on cereal 
and fruit two weeks later. At approximately one week 
of life the baby began to have what the mother 
described as constipation with the passage of one firm 
bowel movement daily initially and then only every 
other day after about two weeks. At about this time 
the mother began to give the child frequent soapsuds 
enemas in order to encourage bowel movements. 
This continued until approximately five v/eeks of life. 
At three weeks of age the baby was noted to have 
patches of Candida on the mucous membranes of the 
mouth, since which time the baby had been quite fussy 
and appeared to be in pain. On this account, the child 
was given paregoric for colic daily until the time of 
admission. Three days prior to admission the baby 
began to have severe diarrhea which gradually pro- 
gressed and necessitated her admission to the hospital 
at six weeks of age. 

Physical Examination'. Her temperature was 99°, 
pulse was 130, respiration was 44 and BP was 90/50. 
On admission she was normally developed but was 
dehydrated and lethargic. Patches of Candida were 
present in the mouth and a Candida rash was present 
on the face, neck, and especially on the arms. The 
fontanelle was soft and slightly depressed. The 
abdomen was flat, without tenderness. No organs or 
masses were felt. The remainder of the physical 
examination was negative. 

Laboratory Studies: Admission HCT was 34%, Hgb 
10.7 gm, WBC count 15,400 with 65% PMN, 36% 
lymphocytes, and 1% monocytes. Urinalysis was 
normal. Glucose was 124 mg%, BUN 8 mg%, sodium 
129, potassium 3.7, chloride 109 mEq/L, C02 13.5 
mM/L. and serum protein 4.5g%. 

Chest x-ray, initial abdominal films, and barium 
enema were normal except for what was described as 
questionable colon enlargement. Eollow-up abdominal 
x-rays on the eighth hospital day demonstrated air-fluid 
levels in the small intestine, but no definite site of 
obstruction was noted. 

Hospital Course'. Over the first two days of hos- 
pitalization the child began to run a spiking fever to 
levels as high as 103° and diarrhea became much 
worse with the passage of 12 green watery stools each 
day. Intravenous fluids were run at a rate of 3000 

*Erom the Division of Pediatric Surgery, Vanderbilt 
School of Medicine, Nashville, Tenn. 37232. 

34 


ml/m2/24hr. Initial cultures of the nasopharynx, urine, 
blood, and cerebrospinal fluid had no growth. The 
stool had no pathogenic organisms isolated, but the 
pH was 5.0, protein 1+ with 4+ glucose and reducing 
substances. Stool guaiac was negative. Despite careful 
intravenous management the child’s diarrhea continued 
although it lessened in amount after oral feedings were 
discontinued. On the ninth hospital day the child’s 
HCT was 27%, sodium 126, potassium 3.1, chloride 
102 mEq/L, C02 16.5, mM/L and protein 2.9g%. 

Surgical consultation was requested at this point 
and examination at this time the infant showed slight 
abdominal distention and somewhat hyperactive bowel 
sounds. No masses were present. Rectal examination 
showed the anal sphincter to be quite lax and some 
blood was present in the stool. It was felt that the 
differential diagnosis was severe infectious colitis or 
colitis caused by low segment Hirschsprung’s disease. 
Two prior attempts had been made to determine sweat 
chloride levels, but these were both unsuccessful due 
to inability to obtain a sufficient specimen. The child 
was extremely ill, and so a colostomy was performed. 
Ringer’s lactate, blood and antibiotics were admin- 
istered preoperatively and the child was taken to the 
operating room. 

A Silastic catheter was placed in the right internal 
jugular vein and brought out a separate incision in 
anticipation of prolonged total parenteral alimentation. 
Then, under local anesthesia, a sigmoid colostomy was 
performed. At the point where the colon was opened, 
numerous ulcerated areas and several white patches 
were noted throughout the gastrointestinal tract, sug- 
gesting Candida infection. Ganglion cells were present 
at the site of the colostomy, but no rectal biopsy was 
performed because of the child’s serious condition. 
Mycostatin was begun orally and topically. Over a 
period of four days the glucose content of intravenous 
fluids was increased from 10 to 20% and amino acids 
from 1.4 to 2.8%. After 13 days on total parenteral 
alimentation, serum proteins had risen from 2.9 to 
4.2 g% and weight had increased to 10 pounds 4 
ounces, which was a pound more than her admission 
weight. On the fourteenth post-operative day, oral 
lactose-free Protagen was begun and she gradually 
was able to increase her oral intake. It was obvious 
however that there was still a great deal of mucus 
production within the colon. On the seventeenth post- 
operative day, stool pH was 8.0 and no glucose was 
noted. On the eighteenth post-operative day, total 
parenteral nutrition was discontinued and the child 
was able to maintain herself on oral feedings. On the 
twenty-third post-operative day, or the thirty-second 
hospital day, the baby was discharged weighing 10 
pounds 14 ounces. 

At three months of age she weighed 12 pounds and 
at four months she weighed 14 pounds 12 ounces. At 
six months of age she was re-admitted to the hospital 
for a rectal biopsy which did show ganglion cells, in- 
dicating that this probably represented a severe colitis 
secondary to Candida infection rather than low seg- 
ment Hirschsprung’s disease. 

The child continued to improve and at 8 months of 
age she was re-admitted to the hospital for colostomy 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


closure. However, she was found to have a stenotic 
area within the sigmoid colon which was felt to be 
secondary to her previous colitis. Because of this, 
sigmoidoscopy and dilatation of the stenotic area were 
performed instead. She was discharged with the plan 
of continuing dilatation on an out-patient basis until 
such time as the colostomy can be closed. In the 
meantime she continues to gain and to thrive. 

DR. JAMES A. O’NEILL: We are most 
fortunate to have Dr. Raymond Amoury, 
Surgeon-in-Chief, Children’s Mercy Hospital, 
Kansas City, Missouri, with us today. He has 
had a longtime interest in the problem of en- 
terocolitis in infants and children. 

DR. RAYMOND AMOURY; This is an 
extremely interesting case and it is my feeling 
that the baby probably had a specific type of 
enterocolitis, most likely due to Candida albi- 
cans, and that this later led to the development 
of a stenotic lesion in the sigmoid colon. I too 
have been confronted with the problem of dif- 
ferentiating between enterocolitis due to 
Hirschsprung’s disease and infectious colitis due 
to other causes in the sm.all infant. Usually, the 
child with Hirschsprung’s disease has persistent 
abdominal distention, and I gather that this 
child had only mild distention, which was not a 
prominent feature of her clinical course. 

DR. O’NEILL: That is correct. 

DR. AMOURY: In low segment Hirsch- 
sprung’s disease, it may be difficult to substanti- 
ate the diagnosis on barium enema. It is even 
more undependable when a baby has severe 
colitis, since evacuation time may not be pro- 
longed. Despite what I have just said, the bar- 
ium enema should usually be done, since it 
often does provide us with a diagnosis. When 
possible, I prefer to perform a rectal biopsy 
prior to doing a colostomy, but when an infant 
is as sick as this one was I think it is reasonable 
to proceed with colostomy, since many infants 
with nonspecific types of colitis will respond to 
colostomy as well. 

At this point it would be well to mention 
that there is a somewhat more benign way of 
establishing the diagnosis of Hirschsprung’s 
disease than obtaining a full-thickness rectal 
biopsy. Shandling and his co-workers in Canada 
have been using a suction biopsy forceps, ob- 
taining a specimen at the first prominent rectal 
fold. The biopsy is of mucosa and subcucosa 
and, in the hands of an experienced pediatric 
pathologist, this appears to be a reliable method 
of determining whether ganglion cells are present 


or not. The classical method of pathologic 
diagnosis is to assay the presence or absence of 
ganglion cells between the longitudinal and cir- 
cular coats of muscularis, but we now know 
that this is not always necessary if the pathol- 
ogist is experienced in interpreting more super- 
ficial specimens. The advantage of this method 
is that a child does not need to be anesthetized, 
and the incidence of complications is essentially 
nil. The correlation between submucosal and 
full-thickness rectal biopsies is fairly good. The 
method is quite tedious, and it may take two 
or three hours to completely analyze the tissue. 

If ganglion cells are noted, this presumes that 
embryologically this cell population has migrated 
out of the neural crest into the muscle coats and 
the submucosa. Hence, if ganglion cells are 
seen in the submucosa, one may assume that 
they are present in the muscularis. On the other 
hand, if no ganglion cells are seen in the sub- 
mucosa, many pathologists feel that a full-thick- 
ness biopsy should be performed. 

DR. O’NEILL: We have a suction biopsy 
forceps designed by Helen Noblett in Australia. 
Interpretation of the submucosal biopsies is in- 
deed difficult and tedious but it is possible. If 
our pathologist sees definite ganglion cells he 
will report them, but he will not report a speci- 
men as showing Hirschsprung’s disease if gan- 
glion cells cannot be found. Under these 
circumstances we feel that we must have a full- 
thickness biopsy. The latter method is still our 
main mode of establishing the diagnosis of 
Hirschsprung’s disease. 

We are presently initiating the use of ano- 
rectal pressure measurements in infants whom 
we suspect may have Hirschsprung’s disease. 
This is especially valuable in very small infants, 
whereas rectal biopsy is difficult in small sub- 
jects. 

DR. AMOURY: I think that this baby was 
well managed, although it might have been pref- 
erable in retrospect to perform the colostomy 
earlier. I believe that most pediatric surgeons 
would perform a colostomy under the circum- 
stances described and control the site of the 
colostomy, as you did, by performing a biopsy to 
be certain that ganglion cells were present at the 
site where the colostomy was performed. The 
main point to remember is that Hirschsprung’s 
enterocolitis is a lethal disorder. Colostomy is 
extremely helpful and, from the way things us- 
ually turn out, it is rarely done unnecessarily 


JANUARY, 1973 


35 


even if the patient has something other than 
Hirschsprung’s disease. 

DR. O’NEILL: As you could tell from the 
presentation, our approach was as it was because 
we felt that this was probably low segment 
Hirschsprung’s disease, although we later found 
out it was not. However, we felt quite secure in 
performing the colostomy, since a large number 
of infants have now been reported who have 
responded to colostomy when all other measures 
failed in the management of nonspecific or in- 
fectious types of colitis. Dr. Amoury, would you 
please contrast this child’s condition with other 
types of enterocolitis seen in infants? 

DR. AMOURY : 1 think this should be dis- 
cussed from the aspect of which layers of the 
bowel wall appear to be involved. This baby ap- 
peared to have a gastrointestinal lesion which 
began on the inside of the intestinal tract, that 
is, the mucosa. There are other types of colitis 
which appear to have their origin within the 
muscular wall and extend inward. This is us- 
ually more of an adult problem as with vascular 
occlusion secondary to atherosclerosis. Oc- 
casionally stenotic lesions are seen in adults with 
the latter type of difficulty. Another type of 
problem which appears to involve the full-thick- 
ness of the bowel wall in some instances and 
only the mucosa in others is necrotizing entero- 
colitis of the newborn. This entity may well 
have its origin during periods of low splanchnic 
flow in especially small infants in the early 
postnatal period. 

Necrotizing enterocolitis is a highly lethal 
disorder. Infants with this problem may have 
evidence of pneumatosis coli on abdominal x- 
ray, and this is probably the one contraindica- 
tion to barium enema as a diagnostic tool, since 
perforation is more likely to occur when 
pneumatosis is present. Occasionally these in- 
fants survive, and we are now beginning to see 
infants who have recovered from necrotizing 
enterocolitis who appear months later with par- 
tial high grade intestinal obstruction due to 
intestinal stenosis. Dr. Krasna and his group in 
New York recently reported five infants who 
developed stenotic lesions of the gastrointestinal 
tract following recovery from necrotizing en- 
terocolitis. Four of these infants were treated 
non-surgically and one of the infants had prev- 
iously been operated on. Most of the stenotic 
lesions were in the colon although two infants 

36 


had lesions in the ileum. Resection of these 
areas was necessary. 

There are other infants who develop diarrhea 
secondary to a variety of bacterial organisms. 
On occasion the gastrointestinal floral changes 
result in alteration of mucosal enzyme systems, 
and disaccharide intolerance is a direct conse- 
quence of this. The clinical manifestations of 
the latter process are colitis, diarrhea, and an 
acid stool which contains glucose and reducing 
substances. 

This infant had received antibiotic therapy in 
multiple courses outside the hospital, and in 
addition there is the information that the mother 
had Candida infection during the latter stages 
of her pregnancy. The baby had skin and 
mucous membrane manifestations of Candidiasis 
as well. This almost certainly led to the severe 
diarrhea. Also, involvement of the mucosa in 
the form of ulceration allowed hyphal compo- 
nents to gradually invade the wall of the bowel 
and perhaps to cause further sloughing of the 
mucosa. At times in such situations it is possible 
to see the appearance of secondary bacterial 
invaders with the production of actual pus. At 
any rate I think this is almost certainly the best 
explanation for the formation of the stenotic 
lesion in this child’s sigmoid colon. I hope that 
continued dilatations will allow you to avoid the 
necessity of resection. 

The matter of why some patients become 
rapidly colonized with Candida and others do 
not is of great interest. There are several things 
which can modify the patient’s ability to cope 
with Candida overgrowth and this is familiar 
to all of you. For example, the adult or the 
child who has immunological competency 
manipulated for transplantation or other reasons 
is often susceptible to fungal overgrowth. In- 
dividuals who have debilitating diseases and 
elderly patients with malignancies or children 
with leukemia often develop systemic Candida 
infections. Another group of patients who have 
appeared with this difficulty are those who have 
foreign bodies in their circulatory systems. For 
example, those patients treated by hyperalimen- 
tation with the methods Dr. O’Neill is using and 
indeed is developing at Vanderbilt are quite 
susceptible to Candida sepsis unless great care 
is taken. To begin with, these patients are very 
debilitated, and they usually have been receiving 
multiple courses of antibiotics, which set the 
stage for the migration of Candida from the 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


mouth, where they normally reside in probably a 
third of the population, down the gastrointestinal 
tract. If one adds to this the problem of coloni- 
zation of concentrated glucose solutions as used 
in hyperalimentation, an already susceptible 
patient may have added difficulties with Candida 
sepsis. Dr. O’Neill, what has been the problem 
of fungal infection with hyperalimentation at 
Vanderbilt? 

DR. O’NEILL: We have been quite fortunate 
to have only about 7% of patients on total 
parenteral alimentation have bouts of sepsis and 
only a portion of these have been due to 
Candida. 

Despite the fact that we are always concerned 
about the possibility of infection, there is no 
doubt that total parenteral nutrition was a tre- 
mendous help to this child. We placed a central 
venous catheter in this infant with some concern 
because at the time we performed this procedure 
she had very severe cutaneous Candidiasis. I 
suppose we were fortunate in this particular in- 
stance although we were also extremely careful. 
The infant was managed on nothing but intra- 
venous fluids and yet it was several days before 
colostomy output decreased to a satisfactory 
level. After about 10 days or so colostomy 
output had decreased sufficiently so that oral 
intake could be initiated. As we calculated 
nitrogen balance, it was positive from the first 
day of hyperalimentation onward but it in- 
creased tremendously at the point colostomy 
output decreased and oral intake was started. 
In the same fashion, when we looked at the 
weight curve and the intake in calories per kilo- 
gram of body weight, marked improvements 
were seen at that point as well. On parenteral 
nutrition alone the baby was receiving 120 cal/ 
kg which is a fairly normal intake for a baby, 
but when oral intake was well established with 
what I call a predigested formula, the baby was 
receiving in the range of 140 cal/kg. 

I think that parenteral nutrition along with 
colostomy certainly saved this baby’s life. Either 
one alone would probably not have been suffi- 
cient. In many instances, however, total parenter- 
al nutrition for a period of four to six weeks is 
often all that is necessary to allow for recovery 
of mucosal enzyme systems in infants who have 
severe non-specific or infectious colitis. We 
have now seen a large number of infants with 
such conditions who, when placed on bowel rest 
with good nutrition over a sufficient period of 


time, recover remarkably well. 

This case gave us an opportunity not only to 
discuss various types of colitis in infants but 
also to mention various approaches to diagnosis 
and therapy. I think we are all indebted to Dr. 
Amoury for his fine discussion. 

REFERENCES 

1. Filler, R, and Eraklis, A: Care of the criti- 
cally ill child; intravenous alimentation. Pediatrics 46: 
456, 1970. 

2. Krasna, I, Becker, J, Schneider, K, and Beck, A: 
Colonic stenosis following necrotizing interocolitis of 
the newborn. J Ped Surg 5:200, 1970. 

3. Touloukian, R, Berdon, W, Amoury, R, and 
Santulli, T: Surgical experience with necrotizing en- 
terocolitis. J Ped Surg 2:239, 1967. 


WANTED 

EMERGENCY ROOM PHYSI- 
CIAN — 400-bed JCAH Hospital, 
serving regional area of 400,000. 
No nights or weekends. Salary and 
activities negotiable and compet- 
itive. Tennessee License manda- 
tory. Excellent fringe benefits. 
Progressive community, four col- 
leges. Contact Administrator, 
(901) 424-0424 or send resume 
and request application to Jackson- 
Madison County General Hospital, 
Jackson, Tennessee 38301. 


JANUARY, 1973 


37 



Geriatric Services in Tennessee 

The TDMH has long been concerned about 
the burgeoning problem of our aging population, 
particularly with those older people who are 
mentally impaired. There are over 1500 such 
people receiving long time care in our state 
psychiatric hospitals and another 500 to 1000 
others are seen in a given year at the com- 
munity mental health centers. Add to this those 
other patients from 55 to 65 years of age that 
have many of the impairments of aged people 
and the hundreds that are served annually in 
the out-patient departments of the state hos- 
pitals, and it becomes clear that a major por- 
tion (40%) of the population of the psychiatric 
hospitals fall in the general categories of 
mentally impaired old people. 

Not all of these people need psychiatric care 
and many could be returned to their local com- 
munities if nursing care and other support 
services were available to them at home. These 
would include such services as home health care; 
homemaker services for help in preparing meals, 
cleaning their homes, and doing the basic house- 
hold chores; meals on wheels — day care services 
where they could be taken to a day care center 
while others in the household are at work or 
out of the house for the day; respite services — 
where the elderly persons in the household 
could be cared for in a residential center over 
a weekend or while the family is on vacation; 
organized recreation activities through Senior 
Citizen Centers, Golden Age Clubs, and church 
groups; nursing homes; and many other services 
that could support and sustain mentally impaired 
old people in their own communities close to 
families and friends. Because these kinds of 
services do not exist for most old people who 
need them, there is usually no other place to 
care for them except in the state mental hos- 
pitals if they have some form of mental im- 
pairment. 

The tragedy of this is not that the care for 
old people in the mental hospitals is so poor, 
but that they are removed from family attach- 
ments, from friends, their churches, and all the 
things of community life that help people during 

38 


their years of infirmity. These vital resources 
become cut off because families do not have 
the kinds of help they need to care for their 
loved ones who are struck down by some form 
of mental damage. 

One day care center in the State has about 
20 members attending, not every day, but oc- 
casionally, where they get acquainted with others 
like themselves, and do things together with the 
help of competent people to lead them in crafts, 
music, social activities, and whatever interests 
are expressed by the group. A skilled nurse sees 
them each day and medical care is available. 
There are only two such day care centers in the 
state. Many old people would be welcome to 
stay in their own homes if more of this kind of 
service were available. 

It is very significant that in the year 1972, 
under the leadership of Commissioner C. Rich- 
ard Treadway, M.D., and Assistant Commis- 
sioner Harold W. Jordan, M.D., the TDMH 
decided that the problems of caring for mentally 
impaired old people needed much greater 
visibility throughout the State in order that 
more extensive forms of service at the com- 
munity level could be generated that would 
provide more positive alternatives to long term 
hospitalization. The hospitals have had to ad- 
mit these people for years, and this will continue 
if alternatives are not found. 

As of July 1, 1972, in the Division of Psy- 
chiatric Services, under the direction of Harold 
W. Jordan, M.D., a section on Geriatric Services 
was created for the specific purpose of helping 
the TDMH and the State of Tennessee to: 

1 ) develop alternative ways of caring for the 
mentally impaired old people, 

2) expand and improve upon rehabilitative 
services, 

3 ) work with other departments of state gov- 
ernment, and other public and voluntary 
agencies concerned with the elderly in de- 
veloping an orderly, coordinated program of 
services for those who are mentally impaired, 

4) serve as an advocate for the mentally 
impaired old people. 

It has been said that the elderly are a minority 
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


(10% of the population) and that if you add 
such other minority labels as being poor, being 
black, being a woman, the degree of minority 
becomes compounded. But when you add the 
label of mental impairment, there often is little 
hope for survival as a dignified human being. 


Expanded Role of Area Advisory Groups 

Area Advisory Group members will have an 
expanded role in determining priorities of the 
Tennessee Mid-South Regional Medical Pro- 
gram, according to Dr. Paul E. Teschan, Direc- 
tor. 

According to Dr. Teschan, workshops are 
now being held in the seven strategically located 
areas of the Tennessee Mid-South Regional 
Medical Program by area coordinators in an 
effort to determine health needs, program pri- 
orities and possible solutions to needs in the 
different areas. 

“We hope the RMP Area Coordinators and 
their Area Advisory Groups will provide closer 
team support to their communities, their health 
interests and health activities in the future,” said 
Dr. William Tribble, Acting Director of Opera- 
tions. 

“We are bringing in professional resources for 
these workshops, like Dr. Percy and Dr. Smith 
of Peabody, to act as catalysts.” 

“We hope,” he continued, “to have our Area 
Coordinators work more directly with the Area 
Advisory Groups and to work on health priori- 
ties listed by the groups. We have already held 
workshops for the Area Coordinators here in 
Nashville to help them determine what their 
new role as liaison between the Area Advisory 
Groups and the Regional Medical Program staff 
offices here in Nashville will be.” 

Area Advisory Groups are made up of health 
providers and health consumers in each area. 
Membership ranges from 30 to 60, depending 
on the region involved. 

“When priorities are set by the Area Advisory 
Groups,” said Dr. Tribble, “we hope the area 
coordinators will work with them on their 
priorities under the umbrella of the Regional 


having access to the worthwhile and customary 
things of life. The TDMH hopes to turn this 
course around for many old people into more 
fulfilling ways of living out their later years in 
dignity even with certain mental handicaps. 


Advisory Group and the staff of the Regional 
Medical Program here in Nashville.” 

“Problems in each area will differ,” he con- 
tinued, “and, of course, as solutions are found 
to some problems, others will arise. For that 
reason, these workshops will be held on a 
continuing basis. We hope needs will be up- 
dated as priorities change.” 

“The Regional Medical Program is a con- 
sortium of all health interests in this Region,” 
said Dr. Teschan, “who hope to accomplish 
together those improvements in health care 
which are beyond the scope of any one partici- 
pant to accomplish alone.” 

“Its purpose,” he continued, “is to help im- 
prove availability and quality of health care at 
affordable costs to the Region’s citizens. Its 
method is to provide professional and technical 
assistance in Regional Medical Program grant 
funds for cooperative endeavors. Its governancy 
within this Region assures that program activi- 
ties are directed toward locally-valid and ac- 
ceptable efforts.” 

Area physicians who would like to express 
their views on health needs and possible solu- 
tions in their communities are invited to contact 
their Area Coordinator with details. 

The Area Coordinators are: Mr. Paul Zar- 
bock, Knoxville, 974-2224; Mrs. Betty Wilson, 
Chattanooga, 265-8254; Mr. Sam Matheny, 
Cookeville, 528-1519; Mr. William Yates, Nash- 
ville, 327-9131; Dr. Jules McNemey, Hopkins- 
ville, Kentucky, 502-886-3908. 

Two new Area Coordinators have recently 
been appointed by Dr. Paul Teschan. They are: 
Mr. Richard Eddy, Johnson City, 928-6616; 
and Ms. Sue Patterson, Nashville, 327-9131 
(temporarily located in Nashville, will be per- 
manently stationed in Columbia). 


^ f lOfii fCQioncil mcciiccil 

_ _ _ — 




JANUARY, 1973 


39 



The Cooper Quiz* 

(Answers found on pages 79, 80, 81, 83, 84) 

Answer true or false unless otherwise indicated 

1. There is a detectable circulating carcinoembryonic antigen (CEA) in patients with colonic 
cancer. If CEA is undetectable in the serum of preoperative patients, this suggests that 
the colon lesion is localized and amenable to curative resection. 

2. If the CEA test is negative on a definitive resection patient (postoperatively) this ensures that 
the tumor has been eradicated. 

3. Evaluation of epithelial changes in laryngopharyngeal biopsies for carcinoma in situ utilize the 
same requirements for leison of the uterine cervix. 

4. Candidiasis has been associated with several different endocrinopathies. Which of the fol- 
lowing is most frequently associated? 

(a) hypoparathyroidism (b) Addison’s disease (c) ovarian insufficiency (d) thyroid ab- 
normalities 

5. Airport weapons detectors may be fatal to patients with permanently implanted pacemakers. 

6. During the past five years combination chemotherapy has been used with considerable success 
in patients with Hodgkin’s disease. The current trend is now a single agent and radiation 
given simultaneously. 

7. In early pertussis the drug of choice is (ampicillin) (erythromycin). 

8. Patients with bleeding diathesis associated with myeloproliferative disorders all have defective 
platelet function. 

9. Metastatic choriocarcinoma of the brain, in women, is an incurable lesion. 

10. Severe anemia may produce severe metabolic acidosis. 

11. The signifieant relationship between obesity and hypertension is well recognized. The same 
relationship applies to both renovascular hypertension and essential hypertension. 

12. Of the following three statements concerning the treatment of early syphilis, one is wrong. 
Which one is wrong? 

(a) Penicillin G has less efficaey than it had originally. 

(b) 30 gm. of tetracycline (over a 10 day period) compares favorably with recommended 
penieillin schedules. 

(c) The base form of erythromycin in a 30 gm. dose (over a 10 day period) is an ac- 
ceptable alternate for penicillin. 

13. The Epstein-Barr virus was first discovered in cell culture from a patient with systemic lupus. 


^Published monthly by the Dept, of Medical Education, the Cooper Hospital, Camden, N.J., William 
T. Snagg, MD., Director. 


40 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


14. Epstein-Barr virus studies now have produced evidence that this virus is the etiologic factor 
in connective tissue diseases. 

15. In digitalis intoxication the ECG evidence of intoxication may persist after blood levels are 
back to a therapeutic range. 

16. Regardless of the immediate cause of death in status asthmaticus, autopsies show extensive 
plugging of airways with tenacious mucus, edema of the bronchial walls and infiltration of 
the bronchial walls by eosinophils. 

17. In patients with bronchitis and asthma nebulization of isoproterenol (and other bronchial di- 
lators) will cause a significant fall in Pa02 and PaCOo. 

18. Many patients with multiple myeloma will have pain due to old vertebral collapse. 

19. Radiation therapy to patients who have multiple myeloma and bone pain is not only excellent 
palliation but may prevent pathologic fracture. 

20. If one excludes drug-users, patients on chemotherapy, and in a neonate and omnionitic, 
drug cultures containing more than one organism are indicative of contamination. 

21. Protein excretion rate is not influenced by fluids and diuretics. 

22. It is well known that nosocomial infections have a predominance of gram-negative organisms. 
Intravenous procedures and instrumentation are associated with increased gram-negative in- 
fections. The use of antibiotics does not appear to influence this. 

23. Of the three methods of treating Graves’ disease listed below, which one is most frequently 
complicated by ophthalmopathy? (a) radioactive iodine (b) antithyroid drugs (c) surgery. 

24. Medicine has been setting “safe” levels of exposure for low-level radiation relative to leu- 
kemogenesis. It is now pointed out this “safe” level may not indeed be safe for a certain 
“susceptible” group. 

25. Crohn’s disease of the colon does not recur in the small bowel after ileocolostomy as does 
ulcerative colitis. 

26. Transient neonatal diabetes is a rare self-limiting disease. It is usually seen in infants 
who are large for the gestational age. 

27. Patients with sickle-cell disease are known to have an increased susceptibility to infection. 
It is interesting that microplasmal infections may mimic bacterial pneumonia in these pa- 
tients and that such infections usually respond promptly to erythromycin despite the fact 
that there is no evidence that in vivo eradication can be accomplished with erythromycin. 

28. Cytomegalovirus is transimittable via human milk. 

29. The curative dose of radiation therapy is known for localized Hodgkin’s disease. When aU 
sites are adequately treated relapses probably occur because of untreated microscopic foci 
outside of the field of treatment. 

30. In this Stanford study of sequential radiotherapy and chemotherapy in the treatment of Hodg- 
kin’s disease, the authors are enthusiastic about such a modality. 

31. The principal drug for deep seated fungal infections currently is (a) Amphotericin B (b) 
Ampicillin (c) Genomycin. 

32. Compared to amphotericin B, 5-fluorocytosine is (a) more toxic (b) less toxic. 


JANUARY, 1973 


41 


EIGHTY-FOURTH 
ANNUAL MEETING 

of the 

MID-SOUTH 

MEDICAL ASSOCIATION 

(Formerly Mid-South Postgraduate Medical Assembly) 

FEBRUARY 14, 15, 16, 1973 
at the 

SHERATON-PEABODY HOTEL MEMPHiS, TENNESSEE 

Outstanding speakers will present half-hour lectures on subjects of 
interest to both general practitioner and specialist. A well balanced 
program is scheduled. Make your plans to attend NOW!! 

CLASS REUNIONS: Class of 1933 — June, September, December; 
Class of 1938 — March, June, September, December; Class of 1943- 
March, June, September, December; Class of 1948 — March, June, 
September, December; Class of 1953 — March, June, September, 
December; Class of 1958 — March, June, September, December; Class 
of 1963— March, June, September, December; Class of 1968 — June, 
December. 

lAake Your Plans Now to Attend the 
Mid-South Medical Association 

FEBRUARY 14-15-16, 1973 

MEMPHIS TENNESSEE 


42 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


im 


m 






, EHG 
M the monUi 




A 36 year old, unemployed musician was referred 
for evaluation of recurrent chest pain of two years 
duration. The chest pains were of brief duration and 
were unrelated to exercise. Two weeks prior to ad- 
mission he was hospitalized elsewhere with a diagnosis 
of “probable myocardial infarction.” At that time he 
described the onset of a severe, “tight” sensation in 
his anterior chest which radiated into both arms, 
occurring after eating a large dinner. This was as- 
sociated with mild dyspnea and diaphoresis and per- 
sisted for approximately one-half hour. There was 
no elevation in level of serum LDH, CPK or SCOT. 
At the time of admission to St. Thomas Hospital, phys- 
ical examination revealed a mesomorphic, healthy 
appearing, white man in no distress. Examination of 
the cardiovascular system disclosed no abnormalities. 
The patient was hospitalized for further observation. 
Serial SCOT, LDH and CPK determinations were 
within normal limits. The following electrocardio- 
gram was obtained (Fig. 1). 


II, III and AVF. This pattern might be mis- 
construed to represent an inferior myocardial 
infarction. However, closer scrutiny of the 
electrocardiogram reveals the PR interval to be 

0. 10 seconds. A delta wave is apparent in leads 

1, AVL and the precordial leads. The correct 
diagnosis is pre -excitation (Wolff-Parkinson- 
White)^ syndrome and the marked superior 
orientation of the initial forces (simulating an 
inferior infarction with q wave in leads II, III 
and AVF) is due to this delta wave. The diag- 
nosis of an inferior wall infarction cannot be 
made in this setting. 

In 1953 Drs. Wolff and Richmond called at- 
tention to difficulty in diagnosis of infarction in 
the presence of pre-excitation.^ The anomalous 
early forces in this syndrome may at times 
simulate infarction and conversely electrocardio- 
graphic evidence of myocardial infarction during 
normal conduction may be masked by the de- 
velopment of the anomalous conduction. In 
order to avoid error, therefore, conversion to 




j V 1 : : 

IS 


Bill— 



~ i '"”1” ’ 

m 













-J 





q 






rt 

— T 




, s 



'‘i % 

J ^ 

-r- 


H 

1 




i/;i 

.r 















' ' i 

:;r 



j 




“V; 



Fig. 1 


This admission electrocardiogram shows early 
QRS forces that are very superiorly oriented, 
causing a q wave to appear in standard leads 

From; St. Thomas Hospital, Department of Cardiology, 
Nashville, Tenn. 


normal conduction is desirable. This may occur 
spontaneously or may be induced by maneuvers 
which alter conductivity across the AV node. 
The use of Valsalva maneuver, carotid sinus 
massage, amyl nitrite, atropine, quinidine or 


JANUARY, 1S73 


43 




Fig. 2 


procaine amide have been tried with varying 
degrees of success. 

A subsequent EKG (Fig. 2) obtained during 
normal conduction, shows disappearance of the 
delta wave and initial superior oriented forces 
thus excluding the diagnosis of inferior infarc- 
tion. 

When the diagnosis of pre-excitation syn- 
drome is uncertain from the standard 12 lead 
electrocardiogram, vectorcardiography may be 
of value. The vectorcardiogram (Fig. 3*) 
characteristically shows marked slowing of the 
initial portion of the QRS complex, representing 
the delta wave. This slowing is quite evident in 
Fig. 3* in which bunching of the dots can be 
seen clearly in the initial portion of the loop. 
(The vector loop dots move “head” first.) 

Pre-excitation syndrome is categorized into 
those cases which appear to have the anomalous 
conduction pathway originating in the left ven- 
triele (type A) and those which appear to have 
the anomalous conduction originating in the 
right ventricle (type B). (Those in which the 
origin of the forces are indeterminate have been 
called type C.) The initial forces in this elec- 
trocardiogram are noted to be oriented leftward, 
anteriorly and superiorly. The anterior orienta- 
tion suggests that the origin of the anomalous 

*Fig. 3 appears on page 27. 


conduction is in the left ventricle (type A). 
Superior orientation of delta forces has been 
noted to occur in approximately 30% of pre- 
excitation tracings. 

With the patient conducting normally, a tread- 
mill exercise electrocardiogram was carried out 
and the patient reached a heart rate of 174/min 
(94% of his predicted maximal rate for age). 
There was no chest discomfort during the test 
and there was no ST segment depression during 
or following exercise. Left heart catheterization 
and coronary cineangiography disclosed no 
abnormalities. Although the patient had no 
tachycardia during the course of his hospitaliza- 
tion, it is very probable that the episodes of 
dypsnea and chest discomfort that he described 
are related to the paroxysmal atrial tachycardia 
which so frequently accompanies this disorder.^ 
Harry L. Page, Jr., M.D. 

W. Barton Campbell, M.D. 

REFERENCES 

1 . Wolff, L, Parkinson, J, White, PD, Bundle Branch 
Block with Short PR Interval in Healthy Young Peo- 
ple Prone to Paroxysmal Tachycardia, Amer Heart J 
5: 685, 1930. 

2. Wolff, L, Richmond, J. The Diagnosis of Myo- 
cardial Infarction in Patients with Anomalous Atrial 
Ventricular Excitation (Wolff-Parkinson-White Syn- 
drome), Amer Heart J 45: 545, 1953. 


44 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 




H.R. 1 -SOCIAL SECURITY AMENDMENTS 1972-NOW LAW 

H. R. 1, with some 100 changes in Medicare, Medicaid, maternal and child 
health is now law. The bill provides establishing PSRO's (Professional 
Standards Review Organizations), to police costs and quality of health 
care for Medicare, and Medicaid patients. Following is a brief 
resume analysis of major amendments. It*s important. — Read it. 

Professional Standards Revi ew O ranization s (PSRO ) . . . representing 

a substantial proportion of practicing physicians, would assume respon- 
sibility in local areas, designated by the Secretary of HEW by January 

I, 1974, for comprehensive and ongoing review of services covered under 
Medicare and Medicaid. Review would be made to determine whether 
services provid e d were medically necessary, met appropriate professional 
standards, and in the case of proposed inpatient services, could be 
provided on an outpatient basis or more economically in a facility of a 

different type . O nly organizations representing a substantial proportion 

of physicians would be allowed to establish PSRO’s until 1976. After 
1975 the Secretary could contract with other groups for the performance 
of this review function, but he coul d enter such contracts only after 
finding that local professional groups were unable or unwilling to 
perform the rev iew function. PSRO's would initially be li m ited to the 
rev iew of he alth care provi d ed by or in institutions, and could assume 
review of other services only with the approv al of t h e Secr e tary. 

Utilization Revi ew Requirements . . • Requirement that hospitals and 
ECF's participating in Medicaid or Title V programs must have those 
patient cases reviewed by the same utilization review committee as is 
already reviewing their Medicare cases, (or, if one does not exist, by 
a review group which meets Medicare standards). This requirement may 
be waived, however, where an alternate system has been approved by the 
Secretary. 


Chiropractor Services Under Medicare . • . Includes as a "physician” 
a chiropractor who is licensed as a chiropractor in his state and meets 
federal standards, but is included only for covered services limited to 
treatment by manual manipulation of the spine "to correct a subluxation 
demonstrated by X-ray to exist." 

Prosthetic Lenses • . . The definition of "physician" under 


Medicare would be modified so as to include optometrist, but only with 
respect to establishing the need for prosthetic lenses. 

D isability benefits for disabled persons receiving cash benefits 
under SSA or Railroad Retirement, Includes disabled workers, disabled 
widows and widowers ages 50 to 65; disabled persons 18 or older 
receiving SS benefits for disabilities occurring before age 22. 

Part B Medicare raised to $5.80 monthly, with subsequent increases 
to be related to actuarial rating, and part B deductible goes from $50 
to $60. Automatic enrollment in part B upon part A eligibility unless 
non-participation is elected. 

Medicaid matching funds to states would be reduced in some services 
if HEW determines a lack of ”proper utilization and medical review 
methods. *' 

HEW will be required to develop experiments, demonstration projects 
to test methods of making prospective payments, in addition to experi- 
ments in reimbursement to ambulatory surgical center, elimination of 
three-day hospital requirement for extended care benefits, use of 
institutional, home-maker services as alternatives to post-hospital 
services, provision of day care services, develop method to pay 
physician's assistant, and determine if clinical psychologist’s services 
should be made more available. 

Medicare costs would be limited through authority given HEW secre- 
tary to set prospective costs as ’’reasonable” for certain classes of 
providers of services. 

Limits on Prevailing Charge Levels . . . Limitations on reasonable 
charges, so as not to exceed the higher of the prevailing charge on 
December 31, 1970, or to the prevailing charge level that, as determined 
by the Secretary, would cover 75% of the customary charges made for 
similar services in the same locality in the base year preceding. In 
the case of physician services, limitations are placed on future 
increases, based on economic changes. Payments under the Medicaid and 
Child Health Programs could not exceed the limits established under the 
Medicare program for similar services. Where medical services, sup- 
plies, and equipment do not vary significantly between suppliers, the 
charges could not exceed the lowest charge levels in the area . . . 

HIBAC to study methods of reimbursement for physicians under Medicare 
to evaluate effects on physicians’ fees generally the extent of assign- 
ments accepted by physicians, and the share of total physician-fee 
costs which the beneficiary must assume. The Council is to make 
alternative recommendations to present methods and state a preferred 
method. 

Skilled Nursing Home and Intermediate Care Facility Payments • . . 
Limitation on the average per diem cost for skilled nursing homes and 
intermediate care facilities countable for federal financial participa- 
tion under Medicaid in any quarter to 105% of such costs for the fourth 
quarter of the preceding year, with allowable increases for added 
patient services. 

Payments to Health Maintenance Organizations • . . 


Authorization for 


reimbursement, through a single capitation payment, to qualified HMO's 
making available directly or under other arrangements, such Part A and B 
services as would otherwise be available in the area. A qualified 
organization will have at least 25,000 members, of which not more than 
half are 65 or older, and will have been in operation at least two 
years (or, in a small or sparsely settled community, will have at least 
5,000 members and be in operation at least three years). As incentives, 
the organization will be entitled to half of the savings represented 
by the difference between its costs and average per capita costs in the 
area for beneficiaries not enrolled in the organiation, limited, 
however, to 10% of such average per capita costs* (Federal government 
would not share in losses.) The Secretary is directed to report 
annually to Congress on its experience with this provision. 

Teaching Physicians • . . Reimbursement for services of teaching 
physicians to a nonprivate Medicare patient to be made under Part A 
on an actual cost or "equivalent cost" basis. Exceptions under which 
f ee-f or-service may continue, would include payments for Medicare 
beneficiaries who are bona fide "private patients," and beneficiaries in 
institutions which meet certain charging practices since 1965. 

Advance Approval of Extended Care and Home Health Coverage . . . 
Authorization to the Secretary of HEW to establish, by medical condi- 
tions and length of stay or number of benefits, periods for which a 
patient would be presumed to be eligible for extended care or home 
health care benefits and services. 

Termination of Payments • . . Authorization in the Secretary to 
terminate Medicare, Medicaid, and Maternal and Child Health payments 
to providers of health or medical services found guilty of fraudulent 
representation, excessive charges or furnishing services in excess of 
need or of grossly inferior quality. The Secretary would create program 
review teams, in each state, composed of physicians, other professional 
personnel, and consumer representatives. 

Reasonable Cost of Inpatient Hospital Services . . . Authorization 
under Medicaid and Title V to the States to determine reasonable cost 
of inpatient hospital services in accordance with methods and standards 
developed by the State, but not to exceed reasonable costs under 
Medicare. 

Payments Where Reasonable Cost Exceeds Customary Charges . . . 
Reimbursement for services by providers under Medicare, Medicaid, and 
Maternal and Child Health programs limited to the lesser of the 
reasonable cost of such services under Medicare, or the customary 
charges to the general public for such services, with special provisions 
applicable to a public provider furnishing services free or at nominal 
cost. 

Prohibition Against Reassignment . • . Reassignment of claims would 
be prohibited, thus limiting payment under Medicare and Medicaid 
generally to the patient, his physician, or other person providing the 
service, unless the physician or other person is required as a condition 


of employment to turn his fees over to his employer or unless he has an 
arrangement with the facility in which the services were provided under 
which the facility bills for the services. (Direct payment could also 
be made to a foundation, association, plan, or contractor which provides 
and administers health care through an organized health care delivery 
system, ) 

Unnecessary Admission • • • Authority to the utilization committee 
to notify the physician, patient, and hospital that payment for services 
by Medicare will cease in three days in not only those cases where the 
Committee finds that hospital or extended care stay is no longer 
necessary, but also in cases where admission was not necessary. 

State Health Agency Functions . • . Requirement that the state 
health agency (or other appropriate state medical agency) be the 
certifying agency within the state for health facilities for participa- 
tion in the Medicare, Medicaid, and the Maternal and Child Health 
programs . • . Also required are state plans for the review of the 
appropriateness and quality of health care furnished under Title XIX 
and Title V. 

Medicaid and Comprehensive Health Care . • • Permission to States to 
waive federal statewideness and comparability requirements if a state 
contracts with an organization which has agreed to provide health care 
and services in addition to those offerred under the state plan to 
eligible people who reside in the geographic area served by such an 
organization and who elect to obtain such care and services from the 
organization. Payments could not be higher on a per capita basis than 
per capita payments for other Medicaid recipients in the same general 
geographic area who are not under the proposed arrangement. 

Laboratory Billing of Patients • . . Authorization to Secretary to 
negotiate a payment rate acceptable to laboratories for diagnostic tests, 
which payment will be considered as full charge for such tests. 

Recovery of Incorrect Payments . . . Presumption that any over- 
payment discovered after the expiration of three years will have been 
made without fault on the part of the provider and that no collection 
should be made . . . Additionally, the Secretary would be authorized 
to deny claims for reimbursement made after the lapse of a reasonable 
period of time of not less than one nor more than three years . . . 
Requirement that providers (or physicians or others where they have 
accepted assignments) where collection of an overpayment is made from 
the provider or others, be prohibited, after three years, from charging 
beneficiaries for services found to be medically unnecessary or 
custodial in nature, in the absence of fault on the part of the 
beneficiary. 

Treatment in Mental Hospitals for Individuals under Age 21 . . . 
Authorization of federal matching under Medicaid for eligible children 
under age 21 receiving in-patient care and treatment for mental 
diseases. 


Notice To All Members! 


Your Memberships in the Tennessee Medical Association and Ameri- 
can Medical Association, including subscriptions to The Journal of 
the Tennessee Medical Association and The Journal of the AMA 
expired on December 31. Here’s how to renew them: 

^ Mail your dues immediately to the Secretary of Your County 
Medical Society. 

TMA dues are $80,00. AMA membership dues are $110.00. If you 
don’t know the amount of your County Medical Society dues, check 
with your local Secretary. 

Many members probably will want to send one check to cover local, 
state, and national dues. Make Check Payable To Your County 
Medical Society. 

Your local Secretary or Treasurer will forward state and national 
dues for you and other members to the Nashville Office of the TMA. 
That office will transmit AMA dues to Chicago. 

Remember: As a part of the privileges and services offered to all 
members of TMA, you will receive a year’s subscription to The 
Journal of the Tennessee Medical Association without cost. Dues- 
paying members of the AMA will receive a year’s subscription to 
The Journal of the AMA, Today’s Health, and American Medical 
News. 

The member who becomes eligible for exemption from dues, and wishes 
to take advantage of exemption, should make his wishes known to 
the Secretary of his County Medical Society. After exemption has 
once been established, the member is carried over from year to year, 
unless the status changes and notification is received from your 
County Medical Society. 


JANUARY, 1973 


53 


for members of 


1CNNESSEE MEMOl ASSOCIATION 




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DEPARTING ON MARCH 11, 1973 FROM NASH VI LLE/MEMPHIS, TENNESSEE 


TENESSEE MEDICAL ASSOCIATION 

1 12 Louise Avenue/ Nashville, Tennessee 37203 (615)327-1451 

Gentlemen : 

Enclosed please find $ 


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Tour prices are based on rates and tariffs in effect as of the date printed herein, AITS reserves the right to adjust tour prices in the 
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Wm. T. Satterfield 


pfc/idcniV 

pcic^ 


Closing in on Private Practice 

The steps that lead to complete regimentation of physicians in the 
private practice of medicine have been taken so rapidly that we are being 
lulled into a depressed, non-resistive attitude. Could it be that we have 
adopted a defeatism that says to us — “this had to come; now it has come 
and it’s the law of the land and we have to make the best of it by 
grabbing the few crumbs of planning that are offered us.” 

Medicare revision from “usual and customary” to the 75th percentile 
of several years ago, Phase II with its discrimination against private 
practicing physicians only, and PSRO have come upon us in accelerating 
rapidity. The completion of domination will be in a national health 
plan which seems to be universally accepted as arriving in the next two 
years. 

We objected to Medicare and made some fight against it, warning of 
its prohibitive cost. We indicated our discontent with Phase II, with no 
result. The government has limited private practice physicians to fee 
increases of 2.5 per cent a year — while institutions which employ salaried 
physicians may increase charges up to 6 per cent annually. This applies 
only to our profession — no other. Small businesses are now witnessing 
a removal of price control restrictions. The regulations actually 
discriminate against physicians in private practice. And, Phase II 
probably will be extended in April. We compete with institutions and 
hosptals for services of nurses, technicians, secretaries and clerks, yet 
regulations do not permit us to raise prices and pass on increased costs as 
institutions can. Rents, costs of pharmaceuticals, of auditing fees, of 
legal services and malpractice protection costs may be increased more 
than our allowed 2.5 per cent. Do the fees of physicians actually have 
that much impact on the economy and is this really curbing the rate of 
inflation? Our fees are actually 1.4 per cent of the Gross National 
Product. 

PSRO (becoming law as the Bennett Amendment of (1972) H.R. 1) 
is regulation of “peer review” for physicians. We have had peer review 
for many years — to maintain quality of physician care. Legalized peer 
review is primarily to cut down the cost of care, although it has been 
demonstrated that the cost of public medical care has gone up (in the 
past 15 years) 293%, while private care costs have increased 123%. 

Control of private practice, through the utilization of a proven military 
principle — “divide and conquer” — is progressing rapidly. The blueprint 
for obtaining control has been adhered to. We must accept the law of 
the land as it becomes so. We should endeavor to apply the law to 
the best interest of caring for our patient, which, after all, is what our 
medical practice is all about. 

If there is defeatism in the attitude of private physicians, the only way 
it can be dispelled is by unify of purpose in preserving the high level of 
medical care by dedicated physicians. 


Sincerely, 



President 



joUfllQl 

OF THE 

TENNESSEE MEDICAL ASSOCIATION 
PUBLISHED MONTHLY 

DEVOTED TO THE INTERESTS OF THE MEDICAL 
PROFESSION OF TENNESSEE 

OFFICE OF PUBLICATION, 112 LOUISE AVENUE, 
NASHVILLE, TENN. 37203 

JOHN B. THOMISON, M.D., EDITOR 

ADDISON B. SCOVILLE, JR., M.D., ASSOCIATE EDITOR 

Acceptance for mailing at special rate of postage provided 
for in Section 1103, Act of October 3, 1917, 
authorized July 15, 1932. 


Copyright for protection against republication. Journals 
of the American Medical Association and of other 
state medical associations may feel free to quote 
from this Journal whenever they desire 
merely giving credit to this publication. 


Address papers, discussions and scientific matter to 
John B. Thomison, M.D., Editor, P.O. Box 70, 
Nashville, Tenn. 37202 

Address organizational matters to Jack E. Ballentine, 
Executive Dir., 112 Louise Avenue, Nashville, Tenn. 37203. 

COMMITTEE ON SCIENTIFIC AFFAIRS 
HARRY A. STONE, M.D., Chairman, Chattanooga 
R. L. DeSAUSSURE, M.D., Memphis 
JOHN H. BURKHART, M.D., Knoxville 
HARRISON J. SHULL, M.D., Nashville 
CHARLES E. ALLEN, M.D., Johnson City 
JOHN B. THOMISON, M.D., Nashville 

JANUARY, 1973 


ecPiloficil/ 


Janus — 1973 

Steps to Destruction 

1. Ti\e undermining of the dignity and sanctity of 
the home, which is the basis of human society. 

2. Higher and higher taxes; the spending of public 
money for free bread and circuses for the public. 

3. The mad craze for pleasure; sports becoming every 
year more exciting, more brutal, more immoral. 

4. The building of great armaments when the real 
enemy is within — the decay of individual responsibility. 

5. The decay of religion; faith fading into mere form, 
losing touch M'ith life, losing power to guide the 
people. 

The average age of the world’s great civilizations 
has been 200 years. Nations progress through the 
following sequence: 

From bondage to spiritual faith; from spiritual faith 
to great courage; from courage to liberty; from 
liberty to abundance; from abundance to selfishness; 
from selfishness to complacency; from complacency to 
apathy; from apathy to dependence; from dependence 
to bondage. 

Gibbon: Decline and Fall of the Roman Empire 
56 


January is named for Janus, who had two 
faces, so that he could look both fore and aft 
at the same time. It is appropriate, then, in 
January to look to the future in the light of the 
past, perhaps to learn from previous mistakes. 

Although an editorial may serve as a source 
of information, its primary purpose is to pro- 
voke and stimulate. It represents the writer’s 
reaction to a given set of facts, and a successful 
editorial should not only stimulate the reader to 
agree or disagree, but to start out on his own 
course of thought. Such being the case, the 
above quotation from Gibbon is an editorial 
complete in itself. There are some aspects of it, 
though, which apply to us as physicians in a 
special way, and I should like us to look at them 
item by item, remembering that in 1976 the 
United States will be 200 years old. 

The imdermining of the dignity and sanctity of 
the home, which is the basis of human society. 
According to recently published articles, it is 
almost within our power to produce a breed of 
parentless children, to the apparent delight of 
many women’s libbers. It is now theoretically 
possible, and apparently in the mill of accom- 
plishing, to build a satisfactory artificial womb, 
artificially fertilize in it a selected ovum with a 
selected spermatazoon, and produce a human 
child of pre-selected genetic characteristics, 
sending him into the arms of a waiting surrogate 
mother, formed possibly of warm terry cloth. 
The sociologists or what have you would then 
be free to program him in any way they wished. 
He would be a ward of the state. We would 
keep our population at the desired level, and the 
liberated women would be freed of the joys of 
motherhood — and the child would be unfettered, 
free of parental pressures (and love). 

The implications of this are too devastating to 
consider, yet we must consider them. If we 
say it can’t happen here, we will be inviting 
it, because it will be technically within our 
power; the home would finally be relegated to 
oblivion. 

Higher and higher taxes; the spending of pub- 
lic money for free bread and circuses for the 
public. Everything free for the public! Free 
bread for those who will not work as well as 
for those who cannot. Free health care; cradle 
to the grave security. These have been the 
promises to our people from each administration 
from the New Deal to the Great Society. For 
40 years now we have been led by our dema- 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


gogues to expect their fulfillment and the natives 
are getting restless. 

We physicians must bear our share of the 
responsibility for this. We as a profession and 
often as individuals are beginning to suffer from 
this over-emphasis on rights. When we entered 
medicine we did so affirming that the needs of 
our patients came first. We need to continue to 
remind ourselves of that. While the Federal 
government continues to affirm its belief in the 
rights and dignity of the individual, the bu- 
reaucratic system is such that the opposite often 
results. 

There are literally millions in our country 
who are desperately poor, for whom medical 
care is not even an unfulfilled dream. Many 
who can afford it have only limited access to it. 
Though the solution is complicated and elusive, 
many innovative methods have been proposed 
in answer to these problems. Too often we as 
doctors have opposed them, on economic 
grounds thinly disguised as ethics, and have 
taken little initiative of our own. We should 
be the leaders in seeing that all people get 
adequate medical care. We have listened to and 
have allowed ourselves to be turned off by 
demagogues demanding “the best” medical care 
for everyone. We have seen this to be logistically 
impossible and productive only of mediocrity, 
and so we have too often become defensive, 
forgetting that, in spite of disclaimers to the 
contrary, millions would settle for any medical 
care, even from physicians’ assistants, nurse 
clinicians, and midwives. And so we allow (or 
possibly force) the Federal government to go its 
merry, inefficient, uneconomical, bureaucratic 
way, and we complain about infringement on 
our rights, and our high taxes. 

The mad craze for pleasure; sports becoming 
every year more exciting, more brutal, more 
immoral. 

SOMEWHERE IN SOUTH CAROLINA— With the 
strength and symmetry of a discus thrower, the burly 
red-faced man whirls his body twice around and, 
grunting loudly, hurls the object clenched in his right 
hand high into the sky. 

Which is a little odd, since the object clenched in 
his right hand is — a pigeon. A live, squawking pigeon 
minus a few tail and wing feathers, which the burly 
red-faced man has rudely plucked out. 

Eor the pigeon, that’s just the start of hard times. 
Eor, once he loses his tail and gets flung into the air, 
someone starts shooting at him with a .12-gauge 
shotgun. If he gets shot and plummets to the ground, 
ladies applaud and men cheer and pay off their $50 


bets. The pigeon may be dead or wounded. Either 
way, he is left on the ground until the shooting of 
other pigeons is done with. Then, either way, he is 
stuffed in a large garbage can and carted off to the 

city dump. 

This is called a sport. Throughout the South and 
the Southwest it is a very popular one, especially with 
wealthy people who gamble lots of money on whether 
the tail-less pigeons hurtling through the air will get 
blown apart. It is called a “pigeon shoot,” and it can 
be an elaborate affair that runs for a couple of days. 

“A lot of people just don’t understand,” complains 
the promoter here, dressed to kill, as it were, in a 
buckskin coat, fancy Indian hat with feather, and 
alligator boots. “A lot of do-gooders think this is cruel, 
but it’s really a heck of a sport. 

The building of great armaments when the 
real enemy is within — the decay of individual 
responsibility. The reference here is obviously 
to national armaments, but the dependence on 
force is an individual matter and depends upon 
the inner resources of the individual. We are 
quite simply reaping the benefits of our previous 
callousness. Fear and resentment build on fear 
and resentment, and ultimately lead to violence 
and revolution. The human spirit will simply 
not remain in bondage. Its manner of reacting 
will depend upon its spiritual values. This is an 
individual matter, and depends upon individual 
responsibility. Responsibility is learned, and 
only from example. If those in authority and in 
positions of responsibility do not act responsibly, 
the result is chaos. The answer is not in walls 
and locks or force of arms. The young tend to 
act as they see their elders act, but tend often 
to over-react. If their elders react in prejudice, 
fear, and hate, that which was controlled in their 
elders becomes in the young active rebellion and 
violence, and the pattern of life is established. 
It behooves us as physicians, as responsible 
members of the community, to be sure of the 
example we are setting, not yielding to the 
temptation to cut corners because “everyone 
else is doing it.” 

The decay of religion; faith fading into mere 
form, losing touch with life, losing power to 
guide the people. The answer to this, and to all 
of the above, lies here. It was stated over 2,500 
years ago: “A new heart also I will give you, 
and a new spirit I will put within you: and I 
will take away the stony heart out of your flesh, 
and I will give you an heart of flesh. And I 
will put my spirit within you, and cause you to 
walk in my statutes, and ye shall keep my judg- 
ments to do them.” (Ezekiel 36:26-27) 


JANUARY, 1973 


57 


The existential philosophy, that there are no 
absolutes, but that each situation must be con- 
sidered in its own light, has led to erosion of 
morals. A sober, thoughtful look at the Ten 
Commandments, and then at our world, should 
convince us of their abiding validity. Man sins 
against God by putting all sorts of gods before 
Him — money, power, things, some of them his 
neighbor’s, often his neighbor’s wife. His sins 
against his neighbor result in wars, collective 
and private. This has led to a divorce rate in 
this country of 445 per 1000 marriages, and a 
venereal disease epidemic which has become a 
plague which attacks rich and poor alike, as 
rampant in the suburbs as in the ghettos. One 
of our colleagues said on the floor of the AMA 
House of Delegates, “It’s about time we learned 
that the Ten Commandments are good health 
laws.” 

In this issue of the Journal the lead article 
is entitled “Medicine Without an Ethic” It 
touches on some issues which because of the 
tremendous technical sophistication we have de- 
veloped loom large in medical practice today. 
The tragedy for medicine is that it like the 
rest of the world is in danger of seeing its spiri- 
tual values replaced by materialistic determinism. 
This bodes ill not only for the patient, but for 
our profession. 

Our forefathers left their homes because of 
bondage of one sort or another to come to a 
new, unknown world. Though there is a ten- 
dency today in our ultra sophistication to point 
out that many of the early colonists came to 
escape prison, we need to bear in mind that 
the prisons contained not only criminals, but 
overflowed with debtors and pohtical prisoners. 
More important, the leaders were, almost to a 
man, men of vision grounded in spiritual faith. 
From this faith stemmed the courage on which 
our liberty is based. 

We have come a long way in our 200 years 
as a nation — from bondage to spiritual faith; 
from spiritual faith to great courage; from 
courage to hberty; from liberty to abundance. 
Are we now on the downside? Or would it 
be more appropriately asked, how far on the 
downside are we? Have we gone from abun- 
dance to selfishness, to complacency, to apathy? 

Be reminded that trivial misbehavior or lack of con- 
sideration often can lead to results with important 
philosophical implications. Thus, respect given to a 
physician must be earned; it is not self-perpetuating. 
Loss of respect leads to lack of patient confidence, dis- 

58 


satisfaction and exaggerated criticism expressed in un- 
willingness to vote against socialization of medicine. 
On a grimmer note, I recall the lack of respect for the 
dead body in the early days of the Nazi ascendancy. 
It is not too far from this to the crematory ovens of 
Auschwitz with physician cooperation. 

Unless some lead the fight to maintain individual 
responsibility and convince the voters that this is to 
their ultimate advantage, the voters will continue to 
listen and agree with the vocal, violent and articulate 
minority who would lead them into a police state 
conveniently labeled “utopian democracy,” too often 
enforced by the slaughter of millions. Have we so 
soon forgotten the history of perfidy of the Hitlers, 
Stalins, and Maos? 

Physicians must learn the price of short-term gains 
in terms of long-term prices. The only way to do this 
is never to lose sight of the underlying philosophy, 
abstract and often remote as it may seem. Others can- 
not do this for us. We would court even further dis- 
aster were we to surrender decision-making to a federal 
government already so overburdened that decisions on 
the military, foreign policy, currency and welfare, to 
mention but a few problems, leave so much to be 
desired.2 

Next in line to dependence comes full circle, 
bondage. There are encouraging signs on the 
horizon, but we must be sure that the medical 
profession generally and physicians individually 
bend every effort not only to prevent further 
erosion, but to provide wise and responsible 
leadership for further progress. J B T 

REFERENCES 

1. The Wall Street Journal, Nov. 28, 1972. 

2. Page, IH, Modern Medicine, Editorial 23:51-53, 
Nov. 13, 1972. 

Volunteer Physicians for Viet Nam 

Military activity for almost a generation has 
left behind in South Viet Nam a mass of suffer- 
ing humanity, from a war in which there have 
been incredible numbers of civihan casualties, 
both directly from military action and from its 
side effect. 

In the summer of 1965 “Project Viet Nam” 
was initiated under the direction of the People 
to People Foundation. The following year the 
project was redesignated the “AMA Volunteer 
Physicians for Viet Nam Program,” funded 
through the State Department. The request to 
AMA was to maintain 32 volunteer physicians 
of specified specialties in Viet Nam at all times. 
This was reduced in 1971 to 24, and was further 
reduced to 14 in 1972. 

During the seven years the program has oper- 
ated, more than 750 U.S. physicians have 
served more than 950 tours of 60 days each 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


in provincial hospitals in South Viet Nam, 
among them 8 from Tennessee; Drs. Joe Bryant, 
Lebanon; Richard France, Nashville; Brett 
Gutsche, Memphis; Nat Hyder, Jr., Erwin; 
Curtis McGowan, Clarksville, Walter Pyle, 
Franklin; Paul Spray, Oak Ridge; John Wolaver, 
Knoxville. 

In 1973, emphasis will be placed on the 
teaching-preceptorship role of the volunteer 
physicians. While there will be a continuous 
need for a pure service role, it is planned that 
Volunteer Physicians for Viet Nam (VPVN) 
will be utilized primarily to establish a “Con- 
tinuing Medical Education” program in Viet 
Nam. 

To maintain the program at its current level 
throughout 1973, it would now appear that 
the AMA must recruit at least 24 VPVN in 
Medicine (Family Practitioners, Internists and 
Pediatricians) a minimum of 24 General Sur- 
geons, and 12 Orthopedic Surgeons. There is 
also a need for 36 VPVN in the other specialties 
to include Anesthesiologists, Ophthalmologists, 
Otolaryngologists, Psychiatrists, Radiologists and 
specialists in Physical and Preventive Medicine. 

Why not give some thought to joining your 
colleagues in an errand of mercy to the un- 
fortunate sick and injured population of South 
Viet Nam? 

J.B.T. 

Hyder, NE: AMA Volunteer Physicians for Vietnam. 

Tennessee GP Third Quarter 1968, 14-32. 

Smilkstein, G: Volunteer Physicians for Viet Nam, 

JAMA 219:495, Jan. 24, 1972. 

Spray, P: Orthopedic Surgery in Vietnamese Provincial 

Hospitals, J Tenn Med Assoc 61:792-797 (Aug) 

1968. 

Viet Nam Civilians Aided — JAMA 221:924 Aug. 21, 

1972 (International Comments) 

U. S. Drug Crisis 

Occasionally there is a book of such import 
that it requires a wider exposure than is af- 
forded by the Book Review Column. Stephen 
L. de Felice, M.D., President of Clinical Re- 
sources, Inc., a subsidiary of MEDCOM, Inc., 
has written a book called Drug Discovery: The 
Impending Crisis. His views are summarized as 
a special item in this issue, which is an address 
which he has delivered before various profes- 
sional groups. 

Dr. de Felice is well qualified to write this 
book, having been trained in general medicine, 
endocrinology and clinical pharmacology. He 


was Chief of the Section of Clinical Pharmacol- 
ogy at Walter Reed Army Institute of Research, 
following which he rose through various assign- 
ments to the position of Medical Director of 
Phizer Laboratories, which he held for two years 
prior to accepting his present position. 

Dr. de Felice’s report simply emphasizes 
what has been pointed out on numerous oc- 
casions in these columns: we seek total protec- 
tion by government agencies at our peril. Over- 
regulation stultifies, and kills initiative, but worse 
still, in this instance, it makes new drug devel- 
opment impossible. To be freed of all risk, in 
any area, is to be imprisoned. We in this coun- 
try are in danger of locking ourselves in a prison 
of our own design and manufacture. 

J.B.T. 

de Felice, SL, Drug Discovery: The Impending Crisis. 
Medcom Press, 2 Hammarskjold Plaza, New York 
10017, 1972. $9.95. 



JONES, ULYSSES G., Johnson City, died November 
11, Age 88. Graduate of Lincoln Memorial Univer- 
sity, 1914. Member of Washington-Carter-Unicoi 
County Medical Association. 

THOMAS, A. LEE, Memphis, died November 29, 
Age 48. Graduate of University of Tennessee Col- 
lege of Medicine. Member of Memphis-Shelby Coun- 
ty Medical Society. 


new mcmbcf/ 


The Journal takes this opportunity to welcome these 
new members of the Tennessee Medical Association. 

CHATTANOOGA-HAMILTON COUNTY 
MEDICAL SOCIETY 

Allen David Lewis, M.D., Chattanooga 
Pete S. Soteres, M.D., Chattanooga 

CONSOLIDATED MEDICAL ASSEMBLY 

Warren Ramer, Jr., M.D., Lexington 
LaMar A. White, M.D., Friendship 

MEMPHIS-SHELBY COUNTY 
MEDICAL SOCIETY 

John M. Gregory, M.D., Memphis 
John C. Morrison, M.D., Memphis 

SULLIVAN-JOHNSON COUNTY 
MEDICAL SOCIETY 

James A. Pettigrew, M.D., Bristol 


JANUARY, 1973 


59 




iKilioiKil ncul/ 


THIS MONTH IN WASHINGTON 
(From Washington Office, AMA) 

Congressional leaders have given national 
health insurance a high priority, but the new 
Congress convening this month may not act on 
it until late this year or even next year. 

Senate Democratic Leader Mike Mansfield of 
Montana assigned the legislation “the highest 
priority” and expressed confidence that a na- 
tional health insurance program will be approved 
during the next two years by the 93rd Congress. 

The key congressman on this legislation, Rep. 
Wilbur D. Mills (D., Ark.), chairman of the 
House Ways and Means Committee, has de- 
scribed the 93 rd Congress as moving “to fashion 
a national health insurance program which the 
great bulk of Americans can support.” 

The three major national health insurance 
bills before the Congress will be the Nixon Ad- 
ministration’s proposal financed by employer- 
employee contributions, the American Medical 
Association’s Medicredit plan and legislation 
sponsored by Sen. Edward M. Kennedy (D.- 
Mass.). 

The Ways and Means Committee acts first on 
such legislation and it had been expected to take 
up tax reform and possibly pension plan legisla- 
tion before national health insurance. This would 
have deferred national health insurance for at 
least several months. But the time-table has not 
been definitely set and Mills recently indicated 
that tax reform might be given a lower priority. 

Another piece of legislation of major im- 
portance to the medical profession that will be 
before the 93rd Congress deals with Health 
Maintenance Organizations (HMO’s). The Sen- 
ate last year approved a bill authorizing a broad 
HMO program and the House Health Subcom- 
mittee approved a much more limited program. 

Democrats remain in control of Congress and 
the key congressmen on health care legislation 
will continue to be Mills; Kennedy, chairman of 
the Senate Health Subcommittee; Rep. Paul G. 
Rogers (D.-Fla.), chairman of the House Health 
Subcommittee; and Sen. Russell B. Long (D.- 
La.). 

Both the Ways and Means Committee and 
the Senate Finance Committee held extensive 
hearings on national health insurance during the 

60 


92nd Congress but the legislative process must 
start anew because all pending bills die auto- 
matically at the end of a two-year Congress. 

Medicredit, slated for early introduction, is 
being expanded to include home care and 
limited dental benefits. In the 92nd Congress, 
Medicredit had 174 sponsors, by far the largest 
number for any national health insurance legis- 
lation. 

Kennedy, with the support of organized labor, 
sponsored the most costly plan in the 92nd 
Congress. It also called for extensive reorgani- 
zation of the nation’s health care delivery system 
with the government having a dominant role. 
At this writing, he had not disclosed any de- 
tails of his new bill. 

He and Mills have conferred on national 
health legislation to see if they could agree on a 
program. In a recent speech, Kennedy said that 
Mills “and I plan to jointly introduce such 
legislation early next year (1973).” But Mills 
has not gone quite this far, at least in his public 
statements. Last fall Mills said of his talks 
on the matter with Kennedy: 

“We found wide areas of agreement. But 
obviously there were key areas where we did 
not — particularly in the financing and adminis- 
trative areas. It may be that as we continue to 
discuss these areas further agreement can be 
made. I think I will be able to convince him 
that reliance on the Federal treasury and the 
Federal bureaucrat is not the best way to ac- 
complish our common objectives.” 

The Bureau of Narcotics and Dangerous 
Drugs has proposed restricting sales of nine 
barbiturates which were described as highly ad- 
dictive and linked to 1,771 suicides and deaths 
in 17 months. 

The Bureau said the barbiturates are more 
dangerous than heroin. 

“Withdrawal from the use of these drugs can 
be fatal and, in many instances, withdrawal 
symptoms are more severe from a barbiturate 
habit than from heroin addiction,” BNDD Di- 
rector John E. Ingersoll said. 

He identified the barbiturates by their generic 
names as amobarbital, butabarbital, cyclobar- 
bital, heptabarbital, pentobarbital, probarbital, 
secobarbital, talbutal and vinbarbital. He listed 
only five brand-name drugs: seconal (secobar- 
bital), tuinal (amobarbital and secobarbital), 
amytol (amobarbital), neumbutal (pentobar- 
bital) and butisol (butabarbital). 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


The BNDD Director asked the Food and 
Drug Administration to place the nine barbitur- 
ates under the same controls for cocaine, mor- 
phine, codeine, methadone and amphetamine. 

❖ ❖ ❖ 

W. R. Barclay, M.D., assistant executive vice 
president of the American Medical Association, 
said that the AMA reserves the right to reject 
drug advertising even if it conforms to Food 
and Drug Administration regulations. 

Fie said the AMA had accepted the FDA’s 
authority as to drug advertising when it was 
promulgated in 1968 “after determining that 
the regulations would provide adequate screen- 
ing and furthermore would have the advantage 
of being consistently applied to all medical pub- 
lications, not just AMA journals.” 

However, Dr. Barclay added, the AMA re- 
served the further right of rejection, not only 
as to drugs but to other products too, “if the 
proposed ad is judged to be in poor taste, if the 
layout would cause confusion with the editorial 
content of the journal or if the ad is for a 
product, service or book which is not covered by 
FDA regulations and which in AMA’s opinion 
does not meet our standards of acceptability.” 

Dr. Barclay said the impact of advertising on 
drug prescribing, use and misuse is not known. 

“No scientific data have been developed on 
this question, and no reliable method has been 
proposed to acquire such data,” Dr. Barclay 
said. “Ads placed in scientific journals reach a 
well educated, well informed and broadly ex- 
perienced audience that has access to many 
sources of scientific information. Since all 
material in such ads has been judged by FDA 
to be correct and accurate it is difficult to see 
how such advertisements could adversely affect 
prescribing practices. In spite of the plethora of 
information available to physicians, AMA has 
developed and distributed without charge to its 
members its own evaluation of drug products. 
This book is titled AMA Drug Evaluations and 
is usually referred to as “ADE.” Unfortunately, 
we are in no better a position to judge the im- 
pact of this book than we are to judge the 
impact of advertising or editorial copy in our 
journals.” 

Dr. Barclay outlined the AMA’s position at a 
public hearing of the National Council of 
Churches. 

❖ ❖ 

The Department of Health, Education and 


Welfare has ended a 40-year study of the effects 
of untreated syphilis among a group of black 
men in Alabama. 

Assistant HEW Secretary Merlin K. DuVal 
announced the end of the Public Health Service 
study after receiving an investigatory report from 
a HEW-appointed citizens’ advisory board. 

When it began in 1932 in rural Alabama, 
the study involved more than 400 black men 
with syphilis and another 200 who did not have 
the disease and were used for comparisons. Of 
the 125 survivors, 50 were in the nondiseased 
control group. 

In its report to DuVal, the panel said, “No 
convincing evidence has been presented to this 
panel that participants in this study were ade- 
quately informed about the nature of the ex- 
periments, either at its inception or subsequent- 
ly,” and added: 

“The U.S. Public Health Service from the 
onset of the study has maintained a continuous 
policy of withholding treatment for syphilis from 
the infected subjects. There was common medi- 
cal knowledge, before this study, that untreated 
syphilitic infection produces disability and pre- 
mature mortality.” 

“The study of untreated syphilis in black 
males in Macon County, Ala., now known as 
the Tuskegee Syphilis Study, should be termi- 
nated immediately,” the panel said. 

Autopsies to determine the effects of un- 
treated syphilis were discontinued several 
months ago. 

During the experiment at least 28 men are 
known to have died of syphilis. 

❖ ❖ 

Government scientists believe they have found 
the cause of intestinal ffu, the ailment that fre- 
quently sweeps through a community or an of- 
fice causing 24 to 48 hours of nausea, vomiting, 
diarrhea and abdominal cramps in its victims. 

They call it “Norwalk agent.” 

Doctors have generally called the disease 
acute infectious non-bacterial gastroenteritis be- 
cause a specific cause had not been identifiable. 
The ailment is not to be confused with the some- 
times deadly influenza which occasionally causes 
international epidemics. 

Scientific investigators for the National In- 
stitutes of Allergy and Infectious Diseases, 
working from a 1968 outbreak of the disease in 
Norwalk, Ohio, and using the latest techniques 


JANUARY, 1973 


61 


in scientific photography, claim to have captured 
the elusive “Norwalk agent” on film. 

^ ❖ 

Frank J. Rauscher, Jr., M.D., director of the 
National Cancer Institute, says that “some very 
important progress is being made” in cancer 
research and that the day soon may come when 
a single drop of a person’s blood will be tested 
to diagnose the disease. 

“In fact, 1 would say that our knowledge of 
cancer — what causes it, how it can be prevented, 
how to spot it in early stages, and how to treat 
it — has advanced more in the last two years 
than in the previous 50,” Dr. Rauscher said. 

He made his prediction in a copyrighted in- 
terview published in U.S. News & World Report. 

But he predicted that in 1973 about 645,000 
new cases of cancer will be discovered in the 
United States and that 350,000 Americans will 
die from the 100 or so forms of the disease. 

Rauscher said from 300 to 400 institutions 
were grappling with the problems of eancer 
and that they were making “tremendous strides.” 
He estimated the total being spent each year, 
both publie and private, at $750 million. 

Elsewhere on the eancer research front: 

Seven Ameriean caneer scientists went to 
Russia and for two weeks exehanged informa- 
tion on cancer viruses with leading Soviet 
seientists in the U.S.S.R. The exchange was part 
of the U.S. -U.S.S.R. health agreement to share 
research results from cancer, heart disease and 
environmental studies which was signed in 
Moseow in May, 1972, during President Nixon’s 
summit meeting. As part of the exchange agree- 
ment, the U.S. scientific delegation will present 
to Soviet scientists 31 strains of cancer viruses 
affecting chickens, cats, rodents, and non-human 
primates, as well as a possible human tumor 
virus from a muscle cancer. James F. Holland, 
M.D., a specialist in treating cancer by drugs, 
has been named to work in the Soviet Union for 
one year to help carry out the new U.S.-U.S.S.R. 
program. 

— A multi-disciplinary cancer research pro- 
gram will be established at the Weizmann In- 
stitute of Science in Rehovot, Israel, under a 
$447,000 research contract awarded by the 
National Cancer Institute. Several research 
topics will be investigated, including the roles of 
various white blood cell populations in the 
body’s defense against cancer, and methods that 
may induce leukemia cells to mature normally. 

62 


Attempts also will be made to further develop 
tests that offer hope for early cancer detection 
and diagnosis. 


icclkol ncui/ 
in lennc//ee 


Meharry Medical College 

Dr. C. W. Johnson, dean of the Graduate 
School of Meharry Medical College, has an- 
nounced a significantly advanced prototype of 
a “generalized artificial internal organ.” The 
device serves both as an artificial lung or as an 
artificial kidney and does so several times more 
effectively than any other available device. 

Dr. Allen Zelman, assistant professor of 
Biophysics and Neurobiology and head of the 
Artificial Internal Organs Laboratory at Meharry 
Medical College, initiated the project two years 
ago while on a bioengineering post-doctoral 
traineeship at Carnegie-Mellon University, Pitts- 
burgh, Pennsylvania. 

Dr. M. Weissman, associate professor of 
Chemical Engineering and Biotechnology at 
C-M U, conceived the idea of etching capillaries 
onto plates in order to produce a more effective 
artificial lung while Dr. Zelman developed the 
microchannel system and designed the support- 
ing framework. 

The project was funded initially by C-M U 
with an NIH research grant and the final de- 
velopment and construction costs were met 
jointly by C-M U through a NIH research grant, 
and Meharry Medical College through a Minori- 
ty Schools Biomedical Science grant. 

TMS-RMP Names Area Coordinators 

Ms. Sue Patterson and Mr. Richard Eddy 
have been named as new Area Coordinators for 
the Tennessee Mid-South Regional Medical 
Program. 

Ms. Patterson is assigned to the South East 
Tennessee area which includes Bedford, Coffee, 
Giles, Hickman, Lawrence, Lewis, Lincoln, 
Marshall, Maury, Moore, Wayne, Perry and 
Franklin counties. 

Mr. Eddy is assigned to the Upper East Ten- 
nessee area which includes Washington, Sulhvan, 
Hancock, Hawkins, Unicoi, Green, Carter and 
Johnson counties. 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



43 Receive AMA Recognition Award 

Forty-three Tennessee physicians have been 
named recipients of the 1972 Physicians’ Recog- 
nition Award by the American Medical Asso- 
ciation. 

The physicians fulfilled the requirements of 
the Award by participating in Continuing Medi- 
cal Education activities. 

Established by the AMA in 1968, the Award 
is granted to those physicians who have com- 
pleted a minimum total of 150 credit hours of 
condnuing medical education over a continuous 
three-year qualifying period. The qualifying 
period of the 1972 Award began on July 1, 
1969, and ended, June 30, 1972. 

The recipients are: John R. Adams, Mem- 
phis; Andres S. Alisago, Jr., Chattanooga; Hazel 
Earl Atherton, Memphis; Robert O. Baratta, 
Nashville; Edward J. Battersby, Nashville; 
Spencer Y. Bell, Knoxville; Warren R. Berrie, 
Nashville; Robert L. Bomar, Jr., Nashville; John 
H. Burkhart, Knoxville; Richard M. Butler, 
Memphis; John J. Carolan, Nashville; Richard 
F. Carver, Johnson City; Michael S. Clarke, 
Memphis; Blaine C. Collins, Memphis; Archi- 
medes Abad Concon, Memphis; Frederick E. 
Cox, Memphis; Jerry J. Crook, Knoxville; 
William A. Crosby, Dickson; Collin L. Durham, 
Jr., Bolivar; William E. Force, Jr., Athens; 
Mable T. Garner, Nashville; Raymond L. Har- 
grove, Knoxville; Thomas W. Higginbotham, 
Memphis; Robert M. Hollister, Franklin; 
William A. Kean, Nashville; Charles N. KendaU, 
Hendersonville; Carl E. Lane, Nashville; Edward 
W. McReynolds, Memphis; Kenneth Cheuk-Fai 
Pau, Chattanooga; Jesse R. Peel, Nashville; 
Edgar E. Perry, Elizabethton; Billie H. Putman, 
Memphis; Jorge E. Cabrera Salazar, Memphis; 
Arthur T. Scherer, Memphis; Robert H. Shipp, 
Nashville; Monde E. Smith, Jr., Selmer; 
Somkeart Srisupundit, Nashville; Robin M. 
Stevenson, Memphis; Carson E. Taylor, Law- 
renceburg; Troy A. Walker, ClarksviUe; Julian 
K. Welch, Jr., Brownsville; Joan B. Woods, 
Oak Ridge; and KJialid A. Yoosfani, Chatta- 
nooga. 

Chattanooga-Hamilton County 
Medical Society 

The Society held its annual meeting on De- 
cember 5, in the Interstate Building auditorium. 
Officers for the 1973 year were installed. They 
are Charles H. Alper, M.D., president; J. Lee 


Arnold, M.D., president-elect, and Paul E. 
Hawkins, M.D., secretary-treasurer. 

Knoxville Academy of Medicine 

The Academy held its annual meeting De- 
cember 12 in the KAM Building. Review and 
reports of the year’s work were given and new 
officers were installed as follows: Felix G. Line, 
M.D., President; Mark Fecher, M.D., president- 
elect; John R. Nelson, Jr., M.D., vice-president; 
Ira Pierce, M.D., Secretary; William Laing, 
M.D., Treasurer. The Executive Committee in- 
cludes Mary Duffy, M.D., John W. Campbell, 
M.D. and Daniel F. Beals, M.D. The outgoing 
president, Dr. Whittaker, recently appointed two 
special committees, the Ad Hoc Committee on 
East Tennessee Chest Disease Hospital com- 
posed of Richard C. Sexton, M.D., Chairman, 
Alfred D. Beasley, M.D., and Robert W. New- 
man, M.D. Also, an Ad Hoc Committee for 
Distinguished Service Awards of TMA was ap- 
pointed with Robert B. Wood, M.D., Chairman, 
Robert B. Gilbertson, M.D., and John D. 
Moore, Sr., M.D. 

Tipton County Medical Society 

A survey was conducted in Tipton County in 
1969 which revealed that many of the residents 
were suffering from lesions known as actinic 
keratoses. As a result of this survey, the Tipton 
County Medical Society has agreed to participate 
in the treatment of patients showing evidence of 
this problem. The program is being conducted 
in cooperation with the University of Tennessee. 
Medication is already available which has been 
effective in the treatment of these lesions. Dr. 
Z. W. Mally, University of Tennessee Professor 
of Dermatology stated that the patients wiU be 
surveyed at a later date for any signs of re- 
currence of these pre-cancerous lesions following 
the period of treatment and recovery. A major 
pharmaceutical company is supplying the medi- 
cation for the study without charge and the 
local physicians are treating the patients and 
recording results. 


pcf/oncil fieiii/ 


DR. CRAWFORD W. ADAMS, Nashville, was elected 
treasurer of American College of Chest Physicians 
during the October, 1972 meeting in Denver. 

DR. WILLIAM F. BURNETT, Jackson, and DR. 
JAMES T. CRAIG, JR., Jackson, have been initiated 


JANUARY, 1973 


63 




as Fellows in the American College of Surgeons at 
the October meeting of the College in San Francisco. 
DR. DUANE CARR, Memphis, has been named clini- 
cal professor of surgery emeritus at the University 
of Tennessee College of Medicine. 

DR. C. ROBERT CLARK, Chattanooga, was hon- 
ored by the Downtown Sertoma Club with the Ser- 
vice to Mankind Award which is presented for “hu- 
manitarian and civic service to the community.” 

DR. JAMES CLEVELAND, Englewood, has been 
named chairman of the Board of Trustees of Epper- 
son Flospital for 1973. 

DR. THOMAS W. CURREY, Chattanooga, has joined 
DR. C. ROBERT CLARK and DR. H. BARRETT 
HEYWOOD in the practice of orthopedic surgery at 
the Whitehall Medical Center. 

DR. JOHN S. DERRYBERRY, Shelbyville, has been 
named president-elect of the Tennessee Academy of 
Eamily Physicians. Also, DR. ARCH Y. SMITH of 
Signal Mountain was elected vice-president during the 
Association’s recent annual meeting. 

DR. THOMAS C. DUNCAN, Huntsville, Alabama, 
has been elected president of the Board of Directors 
of the University of Tennessee at Martin Alumni 
Council. 

DR. EUGENE FOWINKLE, Nashville, Commissioner 
of Public Health, has been installed as president of 
the American Association of Public Health Physicians. 

DR. DONALD GOSS, Nashville, is serving a ten- 
week tour of duty aboard the SS HOPE. 

DR. JAMES B. GREEN, JR., Memphis, recently spoke 
on “Current Treatment of Breast Cancer” at the meet- 
ing of the Methodist Hospital Auxiliary. 

DR. ERED W. HODGE, Knoxville, has been named 
chief of staff of East Tennessee Children’s Hospital 
succeeding DR. JOHN R. MADDOX, JR. 

DR. BEN E. HOUSE, Jackson, spoke to the Jackson 
Area Lay Unit of the Tennessee Diabetes Association 
at a recent monthly meeting. 

DR. LEWIS HOWARD, Harriman, has announced 
that he will close his local practice and will accept 
a position with Veteran’s Administration. 

DR. G. BAKER HUBBARD, Jackson, served as coun- 
cilor from Tennessee during the recent Southern Medi- 
cal Association meeting in New Orleans. 

DR. CLARENCE L. JONES, Cookeville, and DR. 
GEORGE W. JENKINS, Cookeville have been named 
diplomates of the American Board of Family Practice. 
Dr. Jones was previously in residency in anesthesi- 
ology in Memphis but resumed practicing in Cooke- 
ville on January 1, 1973. 

DR. JAMES G. HUGHES, Memphis, chairman of 
pediatrics at the UT Medical Units, has been ap- 
pointed medical director at Le Bonheur Children’s 
Hospital. 

DR. ROBERT E. LASH, Knoxville, has designed and 
directs the emergency medical service at UT sport- 
ing events. He has assembled a team of about 80 
physicians, nurses, cardio-pulmonary resuscitation tech- 
nicians, paramedics and emergency medical technicians 

64 


to assist spectators who become ill or have accidents 
at sporting events. 

DR. ROBERT P. McBURNEY, Memphis, has been 
elected president-elect of the Baptist Hospital Medical 
Staff. 

DR. VERNON E. McNEILUS, Harriman, has opened 
an office limited to the practice of orthopedics. 

DR. B. E. OVERHOLT, Knoxville, has been elected 
member-at-large of the City Board of Education. 
Dr. Overholt was also the guest speaker at the West 
Knoxville Sertoma Club at a recent weekly meeting. 
DR. ERED OWNBY, Nashville, recently spoke at the 
Manchester Rotary Club in Manchester. 

DR. JOHN D. PARKINSON, Cookeville, has pre- 
sented a series of five lectures on marriage at St. 
Therese Catholic Church in Breen Hall. 

DR. M. E. PERRIN, Chattanooga, was elected presi- 
dent-elect of the 1973 Heart Fund. Also, DR. J. ED. 
STRICKLAND, Chattanooga, was elected physicians’ 
division chairman. 

DR. WALTER A. PETERSON, JR., Chattanooga, has 
formed a partnership with DR. REID L. BROWN for 
the general practice of medicine. 

DR. MAURICE S. RAWLINGS, Chattanooga, was 
guest speaker at the Administrative Management So- 
ciety meeting held recently at the Read House. 

DR. ROBERT E. RICHIE, Nashville, has been named 
chief of staff of Veterans Administration Hospital 
succeeding DR. W. G. GOBBEL, JR. who has re- 
signed after a 14-year tour of duty. 

DR. JERRY ROGERS, Lenoir City, has opened prac- 
tice in association with DR. WALTER SHEA. Dr. 
Rogers comes to Lenoir City from Knoxville where 
he served as Emergency Room physician at Baptist 
and UT Hospitals for three years. 

DR. WILLIAM G. SHELTON, Dyersburg, has retired 
from his position as county health officer after 60 
years in the county. 

DR. JERRY L. SHIPLEY, originally from Cooke- 
ville, has opened practice in Byrdstown in association 
with DR. B. H. COPELAND. 

DR. M. ALFORD TODD, Lafayette, has opened an 
office for the practice of medicine and surgery. 

DR. NAT WINSTON, Nashville, spoke at the dedi- 
cation services at Sequatchie General Hospital in 
Dunlap. 

DR. JOHN B. YOUMANS, Franklin, has been elected 
honorary member in the International Health Society 
of the United States. 

^ 

The following physicians have been named Fellows 
in the American Academy of Family Physicians: Dr. 
Robert Clendenin, Union City; Dr. Thomas G. Cran- 
well, Pikeville; Dr. Paul A. Ervin, Crossville; Dr. 
Charles G. Graves, Jr., Dunlap; Dr. Jack R. Holifield, 
Tiptonville; Dr. Maxwell Huff, Oneida; Dr. Horace 
Mott Leeds, Oneida; Dr. Telford A. Lowry, Sweet- 
water; Dr. Oscar McCallum, Henderson; Dr. Charles 
A. Mitchell, Sparta; Dr. James R. Quarles, Springfield; 
Dr. James H. Ragsdale, Union City; Dr. William N. 
Smith, New Tazewell; and Dr. John B. Turner, Spring- 
field. 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


boekfcvteiur 


Malnutrition, Its Cause and Control, Robson, J. R. K., 
Volumes I and II, Gordon and Breach, New York, 1972. 

These excellent volumes are by John Robson, M.D., 
of the School of Public Health, University of Michigan, 
in collaboration with his colleagues of the same school, 
Francis A. Larkin, Ph.D., and Anita M. Sandretto, 
M.P.H., and with Bahram Tadyyon, Ph.D., of the 
Mashad University, Mashad, Iran. The purpose of the 
authors is to demonstrate malnutrition as an ecological 
problem, relating it to physiology, pathology, human 
behavior, and many factors constituting the ecology of 
food and nutrition. The first two chapters concern 
nutrition as a global problem, and the ecology and 
the etiology of malnutrition. 

The authors have addressed themselves to certain 
questions, such as the manifestations of malnutrition 
and the setting of malnutrition, normal nutritional 
states, and nutritional requirements, evaluation of nu- 
tritional status, and how to promote better nutrition 
and to relieve existing malnutrition. 

The format is good and the text quite readable, with 
numerous excellent photographs, charts, and tables. 
Many linedrawings are present as well. In spite of this, 
it is a technical work, and would not be of much help 
to the practicing physician. It is primarily a work of 
nutritionists, including public health workers and 
nurses. 

Confessions of a Gynecologist by an anonymous M.D., 
Doubleday and Company, New York, 1972. 

I am not sure who this book was written for, 
whether for the medical profession or for the gyneco- 
logic patient, which includes potentially all women. 
Either group would be entertained, and it might also 
be instructive for both groups. The author writes with 
a light touch, while at the same time giving various 
discussions on such things as why he opposes natural 
childbirth and believes fathers should not be in the 
delivery room. He also warns against old wives’ tales 
and helpful advice which he considers to be one of 
the most worrisome aspects of pregnancies, with the 
capability of doing considerable emotional harm to 
unsuspecting young women. 

A note on the dust jacket by Dr. Morris Fishbein 
says, “Every woman would profit by this book, which 
is just like sitting at the doctor’s desk and hearing him 
tell it like it is.” She might indeed, and so might you. 

Female Sex Anomalies, Cary M. Dougherty, M.D. and 
Rowena Spencer, M.D., Harper and Row, Hagerstown, 
Md., 1972. $12.75. 

This well-written and beautifully illustrated book by 
Dr. Dougherty, Clinical Professor of Obstetrics and 
Gynecology at Louisiana University State School of 
Medicine, and Dr. Spencer, Clinical Associate Profes- 
sor of Surgery (Pediatric Surgery), Tulane University 
School of Medicine, is a book which would be more 
useful to the gynecologist and pediatrician than to 
other specialists, but might prove useful to the family 
physician. It is a very complete work in a very nar- 


row field, and goes into the embryology of the female 
reproductive system rather thoroughly. It then takes 
up anomalies in the fetus and infant, and then 
anomalies of the reproductive tract generally. 

The book can be recommended for those interested 
in this narrow field. 

Common Problems In Office Practice: Current Methods of 
Diagnosis and Treatment, Robert B. Taylor, M.D., 
Harper and Row, Hagerstown, Md. Paperback, $9.95. 

This book should be of inestimable value to a 
young practitioner starting out, but just might also be 
of value to a more established practitioner, and he 
would do well to look at the first chapter which has 
to do with office practice in general. Anyone might 
take some pointers from this. 

The book is arranged in major subheadings: Internal 
Medicine, Dermatology, Infectious Disease, Pediatrics, 
Urology, Gynecology, Surgery, Orthopedics, Psychiatry, 
and Drug Abuse. Topics are arranged alphabetically 
under these major subheads. They consist of the major 
problems that a physician will face in his office. As an 
example, under gynecology is listed Contraception, 
Dysmenorrhea, Menopause, Pregnancy, Premenstrual 
Tension, Vaginal Bleeding, and Vaginitis. 

In addition to the thorough coverage, the writing 
style is readable and lucid, and the author writes with 
humor about some vexing problems. Coverage on each 
of the problems includes manifestations, management, 
and special diagnostic procedures. At the end of each 
chapter is a reference list on each subject covered, 
with six to eight pertinent references extending up 
through 1971. This might be a handy volume to have 
around the office. 

Diseases of the Vulva, Nikolas A. Janovski, M.D., and 
Charlas Douglas, M.D., Harper and Row, Hagerstown, 
Maryland, 1972. Cloth, 122 pages plus index. $17.50. 

This small but handsome volume is a very com- 
plete and extensive treatise on the diseases of the 
vulva, written by Dr. Janovski, a pathologist at North- 
western Medical School, and Dr. Douglas, Professor of 
Obstetrics and Gynecology at the University of Lon- 
don. The authors have a particular interest in diseases 
of the vulva, both being founding fellows of the In- 
ternational Society for the Study of Vulvar Disease. 
The work is very extensively illustrated, approximately 
half of the illustrations being beautifully reproduced 
in color. The coverage is very complete, both from a 
clinical and anatomical point of view, including ex- 
cellent photomicrographs. 

In each instance, both diagnosis and therapy are 
given rather complete coverage, and at the end of the 
volume there is a very extensive bibliography, listing all 
of the major American and European contributions to 
the field. 

This volume should prove valuable to the gynecol- 
ogist and gynecologic pathologist, but should also be 
of interest, and probably of considerable help, to the 
family physician who sees gynecologic problems, since 
it covers in addition to the more exotic lesions, those 
commonly found in office practice, and which are treat- 
able in the office. This volume can be highly recom- 
mended to any physician who handles gynecologic 
problems in any way. 


JANUARY, 1973 


65 




Synopsis of Gross Anatomy, 2nd Edition, John B. Chris- 
tensen, Ph.D., and Ira R, Telford, Ph.D., Harper and 
Row, Hagerstown, Maryland, 1972. Paper, 270 pages 
plus index, $10.95. 

For its size, this volume is a rather complete outline 
of anatomy, well-illustrated by line drawings, with 
accompanying tables. The print is quite readable and 
large, with anatomic structures listed in bold face. 
This would not be a substitute for a more complete 
anatomy text, but would be useful as an adjunct to it. 
Its greatest use would probably be in a physician’s 
office, the ward, or the operating room, where a quick 
reference is needed. 

Dermal Pathology, James H. Graham, M.D., Waine C. 
Johnson, M.D., and Elson B. Helwig, M.D., Harper 
and Row, Hagerstown, Maryland, 1972. 790 pages 
plus index, 1155 illustrations, with 77 color plates. 
Cloth, $45.00. 

This beautifully illustrated volume is the long 
awaited product of the Postgraduate Course in Dermal 
Pathology which just completed its 14th annual presen- 
tation. Dr. Graham is currently Professor of Medicine, 
Chairman of the Division of Dermatology, and Pro- 
fessor of Pathology, Director of the Section of Dermal 
Pathology at the University of California Irvine 
Campus. Dr. lohnson is Professor of Dermatology and 
Associate Professor of Pathology at Temple University 
School of Medicine, and Director of the Laboratory of 
the Skin and Cancer Hospital at Philadelphia. Dr. 
Helwig is Chief of Pathology and of the Branch of 
Dermal Pathology, Armed Forces Institute of Pa- 
thology. These three individuals are joined by a number 
of other outstanding members of the field of dermal 
pathology to produce what must be considered the out- 
standing work in this field, and certainly the most 
extensively illustrated. 

The various types of lesions are taken up in se- 
quence, and are discussed both as to clinical manifes- 
tations and histologic appearance. At the end of each 
chapter, there is an extensive reference list, including 
all the major works in a given area. One of the major 
features is a very complete and beautifully presented 
section on techniques for preparation of skin for 
histopathologic study, by Lee G. Luna, HT (ASCP), 
Chief, Histopathology Laboratories Division, Armed 
Forces Institute of Pathology. There is also a section 
on biopsy and gross tissue techniques, and another on 
histochemistry of the skin, by Dr. Johnson, and a 
section on the ultrastructure of the human epidermis 
by Dr. Alvin S. Zelickson. There is a beautiful presen- 
tation of the anatomy and histology of the skin by 
Dr. Herman Pinkus. 

This volume lives up to the expectations of those 
who know the writers. It is an expensive volume, but 
I am sure will be considered a necessity for the 
library of pathologists and dermatologists. 

Textbook of Electrocardiography, by David Littmann, 
M.D., Harper and Row, Hagerstown, Md., 1972. $22.50. 

This well-written book in an attractive format by Dr. 
Littmann, who is on the faculty of Harvard and Tufts 
Medical Schools, is a thorough coverage of the sub- 
ject of electrocardiography. He goes quite thoroughly 
into the electrophysiology of the electrocardiogram, 


discussing the normal electrocardiogram before pro- 
ceeding to the abnormal findings. He then takes up in 
order hypertrophy, with strain, enlargement, and pre- 
ponderance; disorders of conduction; coronary heart 
disease; the electrocardiogram in specific disorders; the 
non-specifically abnormal electrocardiogram; and the 
unknown electrocardiogram. 

There is an extensive reference list at the end of 
each chapter, which appears to be very complete. A 
useful feature is the divided index, which gives an 
index to electrocardiographic features, as well as a 
general index. 

This should be a useful book for students, house 
officers, and internists who work in electrocardi- 
ography. Dr. Littmann states in his preface that “The 
illustrations are sufficiently inclusive to serve as an 
atlas of electrocardiography for the cardiologists and 
internists.” In this I concur. 

BRIEFLY NOTED 

Eaters’ Digest: THE CONSUMERS FACT BOOK OF FOOD 
ADDITIVES, Michael F. Jacobsen, Doubleday and Com- 
pany, Garden City, New York, 1972. 

The Anesthesiologist’s Handbook, Donald G. Catron, 
University Park Press, Baltimore, Md., 1972. Paper, 
140 pages plus index. 

LANGE MEDICAL 
PUBLICATIONS SERIES 

Listed below are more volumes in the series of 
Lange Medical Publications which include handbooks 
and reviews of a wide variety of topics in the medical 
field. These volumes are particularly valuable for 
their inexpensive format and frequent updating. This 
allows them to be kept current, and therefore of par- 
ticular value to the practicing physician as well as the 
student and resident. The listed author are in fact 
only editors, each section being written by an authority 
in the particular topic. Coverage in each of the vol- 
umes is very complete, and it can be recommended 
as a valuable adjunct to office practice. Lange Medi- 
cal Publications, Los Altos, Cal. 1972. 

General Urology, 7th Ed., Donald R. Smith. Paper. 427 
pages plus index. 

Medical Microbiology, 10th Ed., Ernest Jowetz, Joseph L. 
Melnick, Edward A. Adelberg. Paper. 504 pages plus 
index. 

Medical Pharmacology, 3rd Ed., Frederick H. Meyers, 
Ernest Jowetz and Allen Goldfien. Paper. 662 pages 
plus index. 

Current Pediatric Diagnosis and Treatment, 2nd Ed. 
by C. Henry Kempe, M.D., Henry K. Silver, M.D. and 
Donough O’Brien, M.D. Paper, 982 pages plus index. 
$12.00. 

Handbook of Medical Treatment, Milton J. Chatton, 13th 
Ed. Paper. 620 pages plus index. $6.50. 

This small volume is just what it says: a fairly com- 
plete small handbook which will fit in the house officer’s 
pocket or in the doctor's bag. It covers most of the 
common situations quite thoroughly, both by system 
and by topic. It should be quite a valuable little 
volume for almost any physician, student, or house 
officer. 


66 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


cinnouncemenl/ 


CALENDAR OF MEETINGS 

STATE 

April 11-14 Tennessee Medical Association, An- 
nual Meeting, Sheraton-Peabody Ho- 
tel, Memphis 

NATIONAL 


January 22-24 

Society of Thoracic Surgeons, Sham- 
rock Hilton Hotel, Houston 

January 24-28 

American College of Psychiatrists, 
Royal Orleans Hotel, New Orleans 

January 26-28 

Southern Radiological Conference, 
17th Annual, Grand Hotel, Point 
Clear, Alabama 

February 1-6 

American Academy of Orthopaedic 
Surgeons, Las Vegas 

February 7-9 

American Academy of Occupational 
Medicine, Royal Orleans Hotel, New 
Orleans 

February 9-16 

American Society of Clinical Path- 
ologists, Sheraton Wakiki Hotel, 
Honolulu, Hawaii 

February 10-11 

AMA Congress on Medical Educa- 
tion, 69th Annual, Palmer House, 
Chicago 

February 12-15 

Southeastern Surgical Congress, Mar- 
riott Motor Hotel, New Orleans 

March 29-30 

AMA National Conference on Rural 
Health, 26th Statler-Hilton, Dallas 

April 1-4 

American College of Surgeons, Spring 
Meeting, Hilton and Americana 
Hotels, New York 

April 2-7 

American College of Radiology, St. 
Francis Hotel, San Francisco 

April 3-5 

American Academy of Facial Plastic 
and Reconstructive Surgery, Chase 
Park Plaza Hotel, St. Louis 

April 6-8 

American Society of Internal Med- 
icine, Palmer House, Chicago 

April 9-12 

American Academy of Pediatrics, 
Spring Session, Sheraton-Boston Ho- 
tel, Boston 

April 9-13 

American College of Physicians, Con- 
rad Hilton, Chicago 

April 16-18 

American Association for Thoracic 
Surgery, Fairmont Hotel, Dallas 

April 16-19 

American Association of Neurolog- 
ical Surgeons, Century Plaza Hotel, 
Los Angeles 

April 23-28 

American Academy of Neurology, 
Sheraton-Boston Hotel, Boston 

April 25-27 

American Surgical Association, Cen- 
tury-Plaza Hotel, Los Angeles 


ACP Regional Meetings and 
Postgraduate Courses 

1973 REGIONAL MEETINGS 

Louisiana-Mississippi Regional Meeting, American 
College of Physicians, Feb. 23-24, Royal Sonesta Hotel, 
New Orleans, La. INFO: A. Sheldon Mann, M.D., 
1514 Jefferson Highway, New Orleans, La. 70121 

Missouri Regional Meeting, American College of 
Physicians, Feb. 23-24, Ramada Inn, St. Louis, Mo. 
INFO: Thomas F. Frawley, M.D., St. Louis Univ. 
Hospital, 1325 S. Grand Blvd., St. Louis, Mo. 63104 

Alabama Regional Meeting, American College of 
Physicians, March 2-3, Grand Hotel, Pt. Clear, Ala. 
INFO: Alwyn A. Shugerman, M.D., 1815 11th Ave- 
nue, Birmingham, Ala. 35205 

South Carolina Regional Meeting, American College 
of Physicians, March 9-10, Matador Motor Inn, 
Columbia, S.C. INFO: Vince Moseley, M.D., 51 E. 
Bay, Charleston, S.C. 29401 

Virginia Regional Meeting, American College of 
Physicians, March 16-17, Williamsburg Inn, Williams- 
burg, Va. INFO: W. Taliaferro Thompson, Jr., M.D., 
4602 Sulgrave Rd., Richmond, Va. 23221 


1973 POSTGRADUATE COURSES 

These courses are arranged through the cooperation 
of the directors and the institutions involved. Registra- 
tion forms and requests for information are to be 
directed to: Registrar, Postgraduate Courses, Ameri- 
can College of Physicians, 4200 Pine Street, Phila- 
delphia, Pa. 19104. Tuition Fees: ACP Members and 
Fellows, $80; Non-members, $125; Associates, $40; 
Other Residents and Research Fellows, $80. 


Date 


Course Title and Location 


Feb. 8-10, 
1973 


Feb. 26- 
Mar. 2, 
1973 

Mar. 5-8, 
1973 


Mar. 5-8, 
1973 


Mar. 12-16, 
1973 


Mar. 14-16, 
1973 


RECENT ADVANCES IN THE IM- 
MUNOPROPHYLAXIS AND CHEMO- 
THERAPY OF INFECTIOUS 
DISEASES, University of Arizona Col- 
lege of Medicine, Tuscon, Ariz. 

CLINICAL GASTROENTEROLOGY, 
University of Michigan Medical Center, 
Ann Arbor, Mich. 

PROBLEMS OF INTERNATIONAL 
HEALTH, Naval Dept., San Diego, 
Calif. 

MODERN NEUROLOGICAL DIAG- 
NOSIS AND THERAPY, University of 
Miami School of Medicine, Miami, Fla. 

INFECTIOUS DISEASES, University of 
Maryland School of Medicine, Balti- 
more, Md. 

CLINICAL PHARMACOLOGY: RA- 

TIONAL BASIS OF THERAPEUTICS, 
Univ. of California School of Medicine, 
San Francisco, Calif. 


JANUARY, 1973 


67 



Mar. 19-23, 
1973 


Mar. 22-24, 
1973 


Mar. 26-30, 
1973 


Apr. 4-6, 
1973 


Apr. 24-27, 
1973 


Apr. 25-27, 
1973 


Apr. 25-27, 
1973 


May 16-18, 
1973 


May 16-18, 
1973 


May 21-25, 
1973 


May 21-25, 
1973 


May 29- 
June 1, 
1973 


June 4-8, 
1973 


June 13-15, 
1973 


June 18-22, 
1973 


June 25-29, 
1973 


FOUR AND ONE-HALF DAYS OF 
INTERNAL MEDICINE: WHAT’S 

NEW? University of Alabama School 
of Medicine, Birmingham, Ala. 

C L I N I CAL RECOGNITION AND 
MANAGEMENT OF HEART DIS- 
EASE — 1973, University of Arizona 
Medical Center, Tuscon, Ariz. 

CARDIOLOGY — 1973 — TOPICS OF 
CURRENT INTEREST, Mount Sinai 
School of Medicine, New York, N.Y. 

RECENT ADVANCES IN DIAGNOSIS 
AND MANAGEMENT OF PULMO- 
NARY DISEASE, Virginia Mason Med- 
ical Center, Seattle, Wash. 

PULMONARY DISEASE, University of 
Pennsylvania School of Medicine, Phila- 
delphia, Pa. 

HEPATOBILIARY DISEASE IN CLIN- 
ICAL PRACTICE, University of Cali- 
fornia, San Francisco 

ADVANCES IN DIAGNOSIS AND 
MANAGEMENT OF INFECTIOUS 
DISEASE, University of Wisconsin, 
Madison, Wis. 

THE RHEUMATIC DISEASES— 
CLINICAL AND IMMUNOLOGICAL 
ASPECTS, University of Texas South- 
western Medical School, Dallas, Tex. 

CLINICAL AUSCULTATION OF THE 
HEART, Georgetown University Hospi- 
tal, Washington, D.C. 

INTERNAL MEDICINE: CURRENT 
CONCEPTS OF CLINICAL PROB- 
LEMS, University of Cincinnati Medical 
Center, Cincinnati, Ohio. 

INTENSIVE CARE UNITS, St. Vin- 
cent’s Hospital and Medical Center of 
New York, New York, N.Y. 

RECENT ADVANCES IN ENDO- 
CRINOLOGY AND THEIR CLINICAL 
APPLICATIONS, Royal Victoria Hospi- 
tal, Montreal, Que., Can. 

HEMATOLOGY, University of Wash- 
ington School of Medicine, Seattle, 
Wash. 

ONCOLOGY AND CHEMOTHER- 
APY, University of Southern California, 
Los Angeles, Calif. 

CLINICAL ASPECTS OF BLOOD 
TRANSFUSION, Michigan State Univ., 
East Lansing, Mich. 

ADVANCES IN INTERNAL MED- 
ICINE: RECENT PERSPECTIVES, 

1973, Banff, Alta., Can. 


University of Tennessee CME Courses 

The following continuing education courses are 
being offered by the University of Tennessee College 
of Medicine during 1973: 


Date of 

Courses: 

March 5-9, 
1973 

March 17-18, 
1973 

March 26-31, 
1973 

April 2-3, 
1973 

April 12-13, 
1973 

May 9-11, 
1973 

May 9-12, 
1973 


May 14-18, 
1973 

May 20-23, 
1973 


Course: 

Fundamentals of Otolaryngology 

Pediatric Anesthesia 

General Review Course for the Family 
Physician 

A Clinical Approach to Common Skin 
Problems 

Conference on the Exceptional Child 
Pulmonary Disease 

Clinical Electrocardiography (Paris 
Landing State Park Inn, Buchanan, 
Tennessee) 

Intensive Review of the Science of 
Anesthesiology 

Basic Principles of Rhinoplasty 


Vanderbilt University CME Courses 


Dates of 
Courses: 

March 8, 

1973 

March 16-17, 
1973 

March 23-24, 
1973 


April 4-6, 
1973 


April 27-28, 
1973 


May 23-24, 
1973 


July 11-12, 
1973 

Sept. 19-21, 
1973 


Sept. 26-28, 
1973 


Title, Location, Program Coordinator 

Death and Dying, Location to be an- 
nounced, Mr. Robert Reber 

Renal Insufficiency, University Club of 
Nashville, Earl Ginn, M.D. 

2nd Annual Dragstedt Surgery Sym- 
posium, Underwood Auditorium, Van- 
derbilt, John Foster, M.D. 

Critical Care (co-sponsor, American 
College of Physicians), Underwood 
Auditorium, Vanderbilt, Ms. Norma 
Shephard 

Pros and Cons of Group Practice 
(Organization Alternatives in Medical 
Practice), University Club of Nash- 
ville, Paul Slaton, M.D. 

13th Annual Seminary in Psychiatry, 
Location to be announced, Vergil 
Metts, M.D. 

Ky. Med. Assn., Annual Meeting, Lake 
Barkley, Kentucky. 

Endocrinology (American College of 
Physicians), Underwood Auditorium, 
Vanderbilt, Grant W. Liddle, M.D. 

The Injured Child (American Academy 
of Orthopedic Surgeons), Underwood 
Auditorium, Vanderbilt, John Connolly, 
M.D. 


68 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Oct. 10-12, 
1973 


Oct. 25-27, 
1973 


Hypertension (American College of 
Cardiology), Underwood Auditorium, 
Vanderbilt, Lawrence Grossman, M.D. 

Child Neurology, Underwood Audi- 
torium, Vanderbilt, Gerald Fenichel, 

M.D. 


Provocative Allergy Course 

A practical course in the technique of intradermal 
provocative food testing and food injection therapy 
will be offered Saturday and Sunday, March 10-11, 
1973, at the Admiral Semmes Hotel, P. O. Box 1209, 
Mobile, Alabama 36601. The course will also cover 
inhalants, chemicals, drugs, fungi, yeasts, viruses, hor- 
mones, terpenes, air-pollutants, insects, and contact 
dermatitis. 

The registration fee of $125.00 also covers one 
dinner and two luncheons. To register for the course, 
send name, address, and check (payable to Provocative 
Allergy Course) to: Joseph B. Miller, M.D., 3 Office 
Park, Suite 110, Mobile, Alabama 36609. Room 
reservations should be made directly with the hotel. 


22nd Annual Postgraduate 
Course in Pediatrics 

The 22nd Annual Postgraduate Course in Pediatrics 
of the University of Texas Medical Branch will be 
held in Galveston, Texas, March 15 and 16, 1973. 
The course will emphasize “Problems of Office Pedi- 
atrics” with guest lecturers Victor C. Vaughan, II, 
M.D. and John B. Reinhart, M.D. 

This program is acceptable for 112 prescribed hours 
by the American Academy of General Practice and 
registration fee will be $75.00. Further information 
will be furnished by Lillian H. Lockhart, M.D., Chair- 
man, Pediatric Postgraduate Committee, the University 
of Texas Medical Branch, Galveston, Texas 77550. 


Neurotology Course 

The Department of Otolaryngology of the Abraham 
Lincoln School of Medicine and the University of 
Illinois Hospital Eye and Ear Infirmary, University 
of Illinois at the Medical Center, will conduct a con- 
tinuing education course in Neurotology, March 26- 
29, 1973. This four day intensive course will offer 
a didactic and practical review of clinical neurotology 
under the direction of Nicholas Torok, M.D. It will 
be held at the Eye and Ear Infirmary and will include 
basic vestibular physiology and pathophysiology, 
commonly used testing methods applied in functional 
examination of the vestibular organ, using nystagmo- 
graphy, reading and evaluation of the test results, par- 
ticularly the nystagmogram, and correlation with 
audiometric and neurologic findings, final neurotologi- 
cal diagnosis, management and treatment. Patients 
will be tested by participants and the history, symp- 
toms and test results will be discussed in informal 
conferences. Enrollment is limited to twelve. For 
application forms write to the Department of Oto- 
laryngology, 1855 West Taylor Street, Chicago. 



strength 



100 mi* J 

''ERSAPe'^ 

HETACiCUW 
^POR ORAi.^ 
SUSPEHStO" 

AMPICttUH 




new 225 mg./5 ml. 
oral suspension 


JANUARY, 1973 


69 




Gastroenterology Course 

Third annual course in Gastroenterology will be 
presented by the Graduate Medical Education Depart- 
ment of the Alton Ochsner Medical Foundation with 
distinguished faculty of visiting professors, local area 
guests and the staff of the Ochsner Medical Center. 
Consideration is given this year to disease problems 
of the small bowel and colon with approach from 
the standpoint of newer developments in the path- 
ophysiologic processes of these conditions. 

Informality is the rule. Adequate time for ex- 
change of ideas and problems and care examples 
enliven the curriculum. Inquiries concerning this 
course should be directed to; William H. McFarland, 
Administrator, Alton Ochsner Medical Foundation, 
Graduate Medical Education Department, 1514 Jeff- 
erson Highway, New Orleans, Louisiana 70121. 

Pediatric Cardiology 

The Division of Pediatric Cardiology at the Uni- 
versity of Miami will sponsor a symposium on “Con- 
troversial Issues in Pediatric Cardiology, 1973,” to be 
held on Key Biscayne, March 19-22, 1973. Sessions 
will be devoted to the principles of management of 
the infant undergoing intracardiac surgery and will 
include discussions of pre-operative, operative and 
post-operative management; surgical results in spe- 
cific lesions in infants, e.g., pulmonary atresia with 
intact ventricular septum, transposition, tetralogy and 
total anomalous pulmonary veins; palliative surgery — 
status 1973; and recent advances in electrophysiology. 

Master Interpretation of 
Clinical Electrophysiology 

The University of Miami School of Medicine arid 
the Council on Clinical Cardiology of the American 
Heart Association will present a postgraduate semi- 
nar entitled: “Master Interpretation of Clinical Electro- 
physiology” on May 29-31, 1973. The program will 
be held at the Contemporary Hotel at Disney World, 
Lake Buena Vista, Florida. 

Tuition for the course is $150.00 non-members; 
$125.00 Fellows and members of the Council on 
Clinical Cardiology, and Physicians in training. Regis- 
tration is limited to 150. Inquiries should be ad- 
dressed to Dr. Louis Lemberg, University of Miami 
School of Medicine, P. O. Box 875, Biscayne Annex, 
Miami, Florida 33152. 

American Board of Family Practice 
Sets Certification Exam Date 

The American Board of Family Practice will give 
its next written certification examination on October 
20-21, 1973. It will be held in various centers 
geographically distributed throughout the United States. 
Information regarding the examination can be obtained 
by writing Nicholas J. Pisacano, M.D., Secretary, 
American Board of Family Practice, Inc., University 
of Kentucky Medical Center, Annex #2, Room 229, 
Lexington, Kentucky 40506. 

It is necessary for each physician desiring to take 


the examination to file a complete application with 
the Board office. Deadline for receipt of applications 
at the Board office is August 1, 1973. 

National Congress On Medical Ethics 

The Fourth National Congress on Medical Ethics 
will be held April 26-28, 1973, Washington Hilton, 
Washington, D.C. 

Among the subjects to be discussed will be: “What 
is Medical Ethics”; “How Does the Student or the 
Resident or the Nurse See Medical Ethics”; “The 
Teaching of Medical Ethics”; “Medical Ethics and the 
New Biology,” etc. 

American College of Surgeons 
Holds First Spring Meeting 

The American College of Surgeons announces its 
first annual four-day Spring Meeting, in New York, 
April 1-4, at the Americana and Hilton hotels. Eight 
structured postgraduate courses, some supplemented by 
plenary sessions and small workshop discussions com- 
prise the program, which is planned to correlate with 
the Surgical Education and Self-Assessment Program 
(SESAP) of the College. 

Purpose of this new annual meeting is to provide 
a well-rounded educational program based on the Col- 
lege’s interpretation of need, the substantive data 
derived from SESAP, which 12,000 surgeons, including 
Fellows, non-Fellows and residents have now sub- 
scribed to. This now enables the College to plan a 
practical, direct answer to specific needs of the 
modern surgeon. New developments will be empha- 
sized, information will be updated and some areas 
of wider interdisciplinary character will be introduced. 

Fellows of the College will receive official registra- 
tion and hotel forms. Non-Fellows may write to 
S. Frank Arado, American College of Surgeons, 55 
East Erie, Chicago, Illinois 60611. 

Forensic Scientists to Hold 
Annual Meeting In Las Vegas 

The American Academy of Forensic Sciences will 
hold its Twenty-fifth Annual Meeting at the Las Vegas- 
Hilton, Las Vegas, Nevada, February 20-23. The four- 
day event will also include the Fifth Annual Meeting 
of the National Association of Medical Examiners. 

Two General Sessions, on Wednesday and Thurs- 
day mornings, will present respectively, an in-depth 
review of the twenty-five year progress of the forensic 
sciences and the subject of “Suicide.” Some of the 
subjects of general interest to be discussed are: as- 
saultive juveniles; computer-related crimes; the ef- 
fects of methadone on driving ability; case histories 
of two skyjackers; the Clifford Irving Hoax; medico- 
sociological aspects of rape; the criminal confession; 
unexpected natural death in children; and child abuse 
and neglect by drug addicted mothers. 

Further details, including an advance program and 
registration information, may be obtained from Dr. 
James T. Weston, 44 Medical Drive, Salt Lake City, 
Utah 84113. 


70 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Eye Clinic Gifts Needed 

Deductible gift for eye clinic in southwest (Omete- 
pec) Mexico in small Presbyterian hospital is needed. 
Office equipment, surgical equipment and Strontium-90 
Beta Applicator also desirable. Contact: Jerre Minor 
Freeman, M.D., 188 So. Bellevue, Memphis, Tennessee 
38104, tel. 901/726-1941. 

American College of Emergency 
Physicians Symposium 

The American College of Emergency Physicians 
will sponsor a two-day workshop February 7-8 at the 
International Hotel, Las Vegas, Nevada. 

Advanced registration fee for members is $110 and 
for non-members $135. Details may be obtained from 
the American College, 241 East Saginaw, East Lansing, 
Michigan 48823. 


Three Days of Cardiology 

“Three Days of Cardiology for Physicians” will be 
held at Shreveport, Louisiana on March 1-3, 1973. 

The meeting is co-sponsored by the Council of 
Clinical Cardiology of the American Heart Associ- 
ation, Louisiana State University Medical School — 
Shreveport, and the Louisiana Heart Association. 

The theme of the meeting is “Cardiovascular Emer- 
gencies.” 


Family Medicine Review Scheduled at 
University of Kentucky Medical Center 

The Third Annual Medicine Review will be held 
at the University of Kentucky Medical Center, Febru- 
ary 11-17, 1973. Program chairman: Frank Lemon, 
M.D. Registration fee: $175. 42 hours of AAFP credit 
has been requested. For further information contact 
Frank R. Lemon, M.D., Associate Dean for Continu- 
ing Education, College of Medicine, University of 
Kentucky, Lexington, Kentucky 40506. 




❖ 


A Symbol 


to Support . • . 



American Medical 
Association — Education 
and Research Foundation 

535 N. Dearborn St., Chicago 10, IH. 




economy 



BRISTOL LABORATORIES 
Division of Bristol-Myers Co. 
Syracuse, N.Y. 13201 


JANUARY, 1973 


71 




Because you 
practice 

medicine in the 
\blunteer State... 



JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


/ou carry one of the heaviest 
>atient loads in the country, 
iince this may include 
i number of patients with 
;astritis and duodenitis... 

'ou should know 
nore about Librax® 


felps reduce 

nxiety-related G.I. symptoms 

I patient may blame his attacks of gastritis or 
uodenitis on “something he ate” but contribut- 
ig factors may be his job, 
larital problems, financial 
'orries or some other unmen- 
joned source of stress and 
cessive anxiety that 
acerbated the condition. 

/hether it is “something 
e ate” or “something eating him,” adjunctive 
ibrax can help. Librax olders both the antianxiety 
:tion of Librium® (chlordiazepoxide HCl ), that can 
2 lp relieve excessive anxiety, and the dependable 
aticholinergic action of Quarzan® (clidinium Br), 
lat can help reduce gastrointestinal hypermotility 
nd hypersecretion. 


?fore prescribing, please consult complete product information, 
summary of which follows: 

ontraindications: Patients with glaucoma; prostatic hyper- 
jophy and benign bladder neck obstruction; know n hypersen- 
tivity to chlordiazepoxide hydrochloride and/or clidinium 
I'omide. 

Warnings: Caution patients about possible combined effects 
ith alcohol and other CNS depressants. As with all CNS- 
jffing drugs, caution patients against hazardous occupations 
quiring complete mental alertness (e.g., operating machinery, 
'"iving). Though physical and psychological dependence have 
irely been reported on recommended doses, use caution in 
Iministering Librium (chlordiazepoxide hydrochloride) to 
lown addiction-prone individuals or those who might increase 
psage; withdrawal symptoms (including convulsions), following 
scontinuation of the drug and similar to those seen with bar- 
iturates, have been reported. Use of any drug in pregnancy, 
ctation, or in women of childbearing age requires that its 
Dtential benefits be weighed against its possible hazards. As 
ith all anticholinergic drugs, an inhibiting effect on lactation 
lay occur. 

recautions: In elderly and debilitated, limit dosage to smallest 
fective amount to preclude development of ataxia, overseda- 
on or confusion (not more than two capsules per day initially; 
icrease gradually as needed and tolerated). Though generally 
)t recommended, if combination therapy with other psycho- 
opics seems indicated, carefully consider individual pharma- 
Jlogic effects, particularly in use of potentiating drugs such as 
lAO inhibitors and phenothiazines. Observe usual precautions 
I presence of impaired renal or hepatic function. Paradoxical 
•actions (e.g., excitement, stimulation and acute rage) have 
;en reported in psychiatric patients. Employ usual precautions 


Patient-oriented dosage — up to 
8 capsules daily in divided doses 

For optimal response, dosage can be adjusted to suit 
patient needs— 1 or 2 capsules, 3 or 4 times a day. 

To help relieve 
anxiety-linked 
symptoms in gastritis 
and duodenitis 
w •'g adjunctive 

Librax<~^ 

Each capsule contains 5 mg chlordiazepoxide HCl 
and 2.5 mg clidinium Br. 


in treatment of anxiety states with evidence of impending 
depression; suicidal tendencies may be present and protective 
measures necessar>’. Variable effects on blood coagulation have 
been reported very rarely in patients receiving the drug and oral 
antieoagulants; causal relationship has not been established 
clinically. 

Ad> erse Reactions: No side effects or manifestations not seen 
with either compound alone have been reported with Librax. 
When chlordiazepoxide hydrochloride is used alone, drowsiness, 
ataxia and confusion may occur, especially in the elderly and 
debilitated. These are reversible in most instances by proper 
dosage adjustment, but are also occasionally observed at the 
lower dosage ranges. In a few instances syncope has been 
reported. Also encountered are isolated instances of skin 
eruptions, edema, minor menstrual irregularities, nausea and 
constipation, extrapyramidal symptoms, increased and 
decreased libido— all infrequent and generally controlled with 
dosage reduction; changes in EEG patterns (low-voltage fast 
activity) may appear during and after treatment; blood 
dyscrasias (including agranulocytosis), jaundice and hepatic 
dysfunction have been reported occasionally with chlordiaz- 
epoxide hydrochloride, making periodic blood counts and liver 
function tests advisable during protracted therapy. Adverse 
effects reported with Librax are typical of anticholinergic agents, 
i.e., dryness of mouth, blurring of vision, urinary hesitancy and 
constipation. Constipation has occurred most often when 
Librax therapy is combined with other spasmolytics and/or 
low residue diets. 


Roche Laboratories 

Division of Hoffmann-La Roche Inc. 

Nutley, New Jersey 07110 




EE ' 

DRUG DISCOVERY: The Pending Crisis 

STEPHEN L. DE FELICE, M.D.* 

Though a significant historical event has oc- 
curred, it is passing by unnoticed. Drug dis- 
covery has virtually stopped. This crisis has 
occurred despite the fact that the speeial skills 
of the FDA, academia and the pharmaceutical 
industry are better than ever. Only a very small 
percentage of the few who are aware of the 
problem question the existence of this virtual 
cessation — they debate only its cause. 

All analyses to date that have attempted to 
demonstrate this drug decline have been criti- 
cized on different points. But the more sophisti- 
cated analyses clearly illustrate this pattern of 
decline. 

What is so surprising to me is not that drug 
discovery has declined — but that so few voices 
are raised to challenge that decline. 

If one steps back and views the last three 
decades, a definite pattern emerges. The decade 
of the forties produced exciting new drugs such 
as the broad spectrum antibiotics, steroids, anti- 
chohnergics, antihistamines, etc. Though we’ve 
grown more sophisticated since then, these 
events were medical milestones. 

Then came the golden era of the fifties, whose 
breakthroughs are numerous: the macrolides 
(medium spectrum antibiotics), neomycin, poly- 
mixin; chlorpromazine for the treatment of 
schizophrenia; semi-synthetic penicillins that 
combated the penicillin-resistant staphylococcus 
that plagued our hospitals; isoniazide for the 
treatment of tuberculosis; the first oral contra- 
ceptive; useful new minor tranquihzers; superior 
new antidepressants, the oral antidiabetic com- 
pounds, etc. The atmosphere of discovery was 
exhilarating. 

Then something unexpected occurred. As we 
entered the decade of the sixties the availability 
of new drugs dramatieally diminished. The ex- 
citement quickly abated, confidence lessened and 
for the first time pessimism pervaded our vig- 
orous system of drug discovery. What could 
have possibly had such an acute negative effect 

*President, Clinical Resources, Inc., subsidiary of 
Medcom, Inc., New York. 


on such a positive, productive movement? 

“Certitude is for fools,” wrote David Hume, 
and frequently no single event can unequivocally 
be singled out as the sole cause of a subsequent 
event, particularly when dealing with social phe- 
nomenon. And yet, two historic events do sepa- 
rate the golden era of discovery of the 50’s 
from the wasteland of the 60’s — the thalidomide 
tragedy and the Kefauver-Harris amendments. 
The spirit of the latter was certainly related 
to society’s reaction to the former — that drugs 
should, above all, do no harm. 

I submit that attempts at the implementation 
of this noble goal have played a significant role 
in the decline of new drugs. This needed at- 
tempt to control widespread use of untested 
drugs — this strengthening of proper FDA regu- 
latory authority — was mistaken for a need for 
non-scientific controls in drug research. 

Consumerism, paradoxically, has different ef- 
fects in different areas. There is, for example, 
little doubt that the pressures brought upon the 
government forced the auto industry to make 
safer cars. The intent of these pressures, of 
course, is to reduce risk to the consumer. 

Understandably, similar pressure is being ap- 
plied to our drug discovery system in an effort 
to reduce risks with drugs. But human risk 
is an integral part of the drug discovery process. 
Any system, therefore, must be counterproduc- 
tive if it attempts to reduce risk to the degree 
exemplified by one former government official’s 
statement: “This country does not permit, at 
least not in the present day context, a needless 
surrender of one life. This is the ethic that is 
professed.” Were this the proper philosophy, 
and we were today developing penicillin, one 
death resulting from that research might end 
the study, and penicillin would go undiscovered. 

Since the Kefauver-Harris amendments and 
thalidomide, a situation has developed where 
any bad drug event (adverse effect) — be it 
isolated or occurring in animals only — is magni- 
fied to such a degree that severe prohibition of 
clinical investigation has occurred. This has oc- 
curred not only because of regulatory pressures 
but also because consumer pressure is now so 
prevalent that an anticlinical research mentality 
has arisen in the medical community itself. 

Not too infrequently, one hears the ad ho- 
minum argument, “Would you let your father 
take this drug?” This attitude is disturbing, 
since the drugs can only be discovered in man. 


74 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Animals have limited predictability regarding 
the clinical efficacy of drugs. Many of our 
great drugs such as chlorpromazine and dapsone 
(used in the treatment of malaria) were dis- 
covered serendipitously in man. Since thalido- 
mide, however, opinion has turned against 
early and imaginative testing of drugs in man. 
Now, drug researchers must prove safety and 
activity in animals — frequently unachievable — 
before taking a drug to man. 

If nothing else, this book explodes the myths 
about testing drugs in animals. It demonstrates 
that the predictability of biological events from 
animals to man — either good or bad — is not 
very high. Even if some bad events are pre- 
dictable, the book shows why they should not 
hinder the evaluation of a drug in man. Well- 
controlled studies, even with the most toxic of 
substances, can be done very safely. Drug 
tragedies occur with marketed products that 
are widely used, and yet occur very uncommon- 
ly during the investigational phases. Consumer- 
ism, therefore, should concern itself with 
marketed products. 

Will increased clinical experimentation in- 
crease societal risk? Probably the best answer 
can be found in the pages of history. Consider 
the drugs that were introduced over the past 
thirty years — who among us would cast aside 
these drugs? Little would remain in our medical 
armamentarium. The overall societal risk-bene- 
fit ratio clearly favors the benefit aspect of the 
equation. To be sure the great philosophic 
question of the general good versus the par- 
ticular good is key to any position. Philosophers 
have attempted mightily to reconcile both goods 
— and have failed. Societies, however, do not 
have these problems and reconcile both issues 
with facility. For example, penicillin kills many 
people but saves many, many more. The so- 
eiety has accepted penicillin. The risk-benefit 
ratio during this era was not questioned by our 
society simply because there was a general 
confidence in our drug discovery system. The 
forces of this present day consumerism were not 
present and government influence was minimal 
to moderate. Former NIH head Shannon, stated 
that the golden era of drug discovery occurred 
during a laissez faire policy of government. Only 
when government influence increased did drug 
diseovery lose its vigor. 


It appears, therefore, that an almost impos- 
sible situation exists. There is a consumeristic 
movement that in many ways is a good thing 
and is not about to disappear. There is also 
the reality that drug discovery can only be in- 
creased by more frequent and imaginative chni- 
cal research which on the surface appears con- 
trary to the consumeristic spirit. Can these two 
factors be reconciled? 

In this book, I show how this can be done. 
Generally speaking, the proposed objectives are 
twofold; to insulate unnecessary forces of con- 
sumerism from the drug discovery process and 
to create a new medical specialty, clinical drug 
development whose function would be to guide 
worthwhile drugs through the complex maze 
of societal obstacles. Specifically, the proposals 
would be as follows: 

a. Establish residencies of clinical drug devel- 
opment with academic, industry and gov- 
ernment participation. 

b. Remove early, imaginative clinical research 
from the governmental regulatory process. 
Government regulatory agencies are rep- 
resentatives of the consumer and, there- 
fore, bear the brunt of such pressure. 
When a drug becomes “marketable” only 
then should it fully come under the regula- 
tory processes. 

c. Create regional peer groups to which clini- 
cal protocols are submitted and review. 
These peer groups must contain sufficient 
broad knowledge to make a sound judg- 
ment. In this way, one can bring the 
necessary expertise to bear upon the criti- 
cal areas of drug discovery. 

d. And finally, to institute a no-fault type 
of insurance for clinical investigators. The 
latter aspect is critical. 

Unfortunately, in order for the above to 
occur, strong Congressional support is manda- 
tory. This will not come about unless there is 
sufficient support by the media. 

If drug discovery does not rightly come under 
the control of the scientific community, and is 
not removed from undue forces of consumerism, 
then there is little doubt that new important 
drugs will not be forthcoming. If that happens, 
then the first prerequisite to better health care 
for the people will have been ignored. 


JANUARY, 1973 


75 


NEW!! 

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DUNN-LEMLY-SIZER. INC. 
800 Sudelcum Building 
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Rondomycin 

(methacycline HCI) 


CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines. 

WARNINGS: Tetracycline usage during tooth development (last half of pregnancy to eight 
years) may cause permanent tooth discoloration (yeliow-gray-brown), which is more 
common during long-term use but has occurred after repeated short-term courses. 
Enamel hypoplasia has also been reported Tetracyclines should not be used in this age 
group unless other drugs are not likely to be effective or are contraindicated. 
Usage in pregnancy. (See above WARNINGS about use during tooth development.) 

Animal studies indicate that tetracyclines cross the placenta and can be toxic to the 
developing fetus (often related to retardation of skeletal development). Embryotoxicity 
has also been noted in animals treated early in pregnancy. 

Usage in newborns, infants, and children. (See above WARNINGS about use during 
tooth development.) 

All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease 
in fibula growth rate observed in prematures given oral tetracycline 25 mg/kg every 6 
hours was reversible when drug was discontinued. 

Tetracyclines are present in milk of lactating women taking tetracyclines. 

To avoid excess systemic accumulation and liver toxicity in patients with impaired renal 
function, reduce usual total dosage and, if therapy is prolonged, consider serum level 
determinations of drug. The antianabolic action of tetracyclines may increase BUN. While 
not a problem in normal renal function, in patients with significantly impaired function, 
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis. 

Photosensitivity manifested by exaggerated sunburn reaction has occurred with 
tetracyclines. Patients apt to be exposed to direct sunlight or ultraviolet light should be so 
advised, and treatment should be discontinued at first evidence of skin erythema. 
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible organisms, 
including fungi, discontinue antibiotic and start appropriate therapy. 

In venereal diseases, when coexistent syphilis is suspected, perform darkfield exami- 
nation before therapy, and serologicaily test for syphilis monthly for at least four months. 

Tetracyclines have been shown to depress plasma prothrombin activity; patients on 
anticoagulant therapy may require downward adjustment of their anticoagulant dosage. 

In long-term therapy, perform periodic organ system evaluations (including blood, 
renal, hepatic). 

Treat all Group A beta-hemolytic streptococcal infections for at least 10 days. 
Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, avoid 
giving tetracycline with penicillin. 

ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms): anorexia, nausea, 
vomiting, diarrhea, giossitis, dysphagia, enterocolitis inflammatory lesions (with monilial 
overgrowth) in the anogenital region. 

Skin: maculopapular and erythematous rashes; exfoliative dermatitis (uncommon). Pho- 
tosensitivity IS discussed above (See WARNINGS). 

Renal toxicity: rise in BUN, apparently dose related (See WARNINGS). 

Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura, 
pericarditis, exacerbation of systemic lupus erythematosus. 

Bulging fontanels, reported in young infants after full therapeutic dosage, have disap- 
peared rapidly when drug was discontinued. 

Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia. 

Over prolonged periods, tetracyclines have been reported to produce brown-black 
microscopic discoloration of thyroid glands; no abnormalities of thyroid function studies 
are known to occur. 

USUAL DOSAGE: Adults-600 mg daily, divided into two or four equally spaced doses. 
More severe infections: an initial dose of 300 mg followed by 150' mg every six hours or 
300 mg every 12 hours. Gonorrhea: In uncomplicated gonorrhea, when penicillin is con- 
traindicated, 'Rondomycin' (methacycline HCI) may be used for treating both males and 
females in the following clinical dosage schedule: 900 mg initially, followed by 300 mg 
q.i.d. for a total of 5.4 grams. 

For treatment of syphilis, when penicillin is contraindicated, a total of 18 to 24 grams 
of 'Rondomycin' (methacycline HCI) in equally divided doses over g period of 10-15 days 
should be given. Close follow-up. including laboratory tests, is recommended. 

Eaton Agent pneumonia: 900 mg daily for six days. 

Children - 3 to 6 mg/lb/day divided into two to four equally spaced doses. 

Therapy should be continued for at least 24-48 hours after symptoms and fever have 
subsided 

Concomitant therapy: Antacids containing aluminum, calcium or magnesium impair 
absorption and are contraindicated. Food and some dairy products also interfere. Give 
drug one hour before or two hours after meals. Pediatric oral dosage forms should not be 
given with milk formulas- and should be given at least one hour prior to feeding. 

In patients with renal impairment (see WARNINGS), total dosage should be decreased 
by reducing recommended individual doses or by extending time intervals between 
doses. 

In streptococcal infections, a therapeutic dose should be given for at least 10 days. 
SUPPLIED: Rondomycin' (methacycline HCI): 150 mg and 300 mg capsules; syrup con- 
taining 75 mg/5 cc methacycline HCI. 

Before prescribing, consult package circular or latest PDR information. 

Rev, 12/71 

L?Ti WALLACE PHARMACEUTICALS 
i A i CRANBURY, NEW JERSEY 08512 


76 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



ANSWERS TO “THE COOPER QUIZ” 

THE JOURNAL OF THE 
AMERICAN MEDICAL ASSOCIATION 
July 1972 

1. True. “Our findings support the usefulness of 
the CEA assay in patients with colonic cancer. 
Preoperatively, an undetectable serum CEA sug- 
gests that the tumor is localized and therefore 
amenable to curative resection. Conversely, a 
strongly positive result for serum CEA determina- 
tion suggests metastatic disease and implies reduced 
likelihood of surgical cure. 

“When the clinical circumstances are compatible 
with the diagnosis of colonic cancer, patients with 
borderline CEA values should be closely watched. 
This may result in detection of tumor at a rela- 
tively early stage.” (July 3, pg. 35.) 

2. False. “Follow-up studies in our patients, though 
necessarily short, have provided useful informa- 
tion. Contrary to the conclusion of LoGerfo et al, 
a negative CEA test result following presumed 
definitive resection did not ensure eradication of 
disease. Tumor recurrence became obvious in 
several patients during the course of the present 
study, despite negative postoperative CEA test re- 
sults. In view of the low incidence of CEA posi- 
tivity in patients with localized tumors, it is not 
unexpected that small foci of residual tumor may 
escape detection by this test. Repeated follow-up 
CEA determinations often detect antigenemia as 
the residual tumor grows.” (July 3, pg. 35.) 

3. True. “In a classic paper published in 1952, 
Altmann et al first drew attention to a series of 
patients with carcinoma of the larynx in whom 
the malignant changes were largely limited to the 
mucosa. Carcinoma in situ or intraepithelial cari- 
noma of the larynx and pharynx is now widely 
recognized, and with few minor variations there is 
general agreement as to the histologic requirements 
for the diagnosis. These requirements have been 
spelled out best for lesions of the uterine cervix, 
we employ them for laryngopharyngeal lesions es- 
sentially without change. The characteristics in- 
clude replacement of the full thickness of the 
epithelium by cells with the cytologic characteris- 
tics of malignancy, a lack of maturation or dif- 
ferentiation, and an absence of invasion.” (July 3, 
pg- 72.) 

4. (a) “Candidiasis has been associated with several 
different endocrinopathies. Of these, hypopara- 
thyroidism has been the most frequent. Less fre- 
quently, Addison’s disease, ovarian insufficiency 
and thyroid abnormalities have also been observed. 
“This is a case report of a patient in whom 
chronic mucocutaneous candidiasis developed long 
before a diagnosis of marked hypothyroidism could 
be made. Normalization of his thyroid status by 
replacement therapy resulted in dramatic sponta- 
neous improvement of the candidal infection which 
had previously been resistant to a variety of anti- 
candidal treatments.” (July 10, pg. 156). 


5. False. “Fifty-three patients with permanently im- 
planted pacemakers, predominantly of the trig- 
gered unipolar variety, were exposed to the active 
electromagnetic field of a weapons detector. Stan- 
dard unipolar and bipolar ventricular pacers were 
unaffected. Certain sensitive unipolar atrial and 
atrioventricular pacers showed minor temporary 
rate changes that were clinically insignificant. We 
believe that the weapons detector can be safely 
employed with patients who have any of the pace- 
makers tested.” (July 10, pg. 162, “Abstract”) 

6. False. “During the past five years, the use of 
combinations of drugs in cancer chemotherapy has 
become increasingly popular, and remission rates 
in some types of solid tumors have been described 
as being higher than rates with single agents used 
alone. Such tumors include cancer of the testis, 
breast carcinoma, and acute leukemia. In 1964, a 
combination of agents was devised at the National 
Cancer Institute for the therapy of Hodgkins’s dis- 
ease. This combination (MOPP) included mech- 
lorethamine, vincristine sulfate, procarbazine, and 
prednisone, and results of the use of this combina- 
tion have been reported by DeVita et al and by 
Lowenbraun et al. These preliminary results, re- 
ported in 1970, were extremely encouraging. The 
remission rate was superior to that previously 
reported for single drugs, and even more im- 
portant, a substantial proportion of patients re- 
mained continuously free of disease for four years 
even though no maintenance therapy was given. 
On the basis of past experience with single agents, 
with remissions usually lasting significantly less 
than four years, the treatment of choice for ad- 
vanced Hodgkin’s disease (stages III and IV) is 
probably the four-drug MOPP combination, given 
as described by DeVita et al. This consists of six 
two-week cycles of chemotherapy, with two weeks 
between each period of drug administration.” (July 

10, pg. 261.) 

Ed. Note: This paper describes giving combination 
chemotherapy to ambulatory patients in private 
practice. 

7. Erythromycin. “The clinical ineffectiveness of 
ampicillin in eradicating B pertussis as shown in 
this study has been demonstrated by others. Fol- 
lowing the appearance of these reports, subsequent 
patients were treated with erythromycin. To date, 
a total of seven adults have been treated with eryth- 
romycin for presumptive pertussis. In all cases 
the follow-up FA smears five days after onset of 
therapy have been negative. As noted by others, 
if the cough has progressed to the paroxysmal 
stage prior to the onset of therapy, antibiotics do 
not appear to alter the clinical symptoms.” (July 
17, pg. 267.) 

8. True. “Although extensively studied, no consistent 
abnormality of the plasma coagulation system has 
correlated with the bleeding diathesis observed in 
patients with myeloproliferative disorders. Instead, 
the present studies suggest that defective platelet 
function is universally found in these patients, and 


JANUARY, 1973 


79 


that the replacement of the abnormal platelets with 
normal ones may be therapeutically beneficial in 
dealing with hemorrhagic episodes. 

“Although abnormalities in platelet appearance 
have been well described in myeloproliferative dis- 
orders, attempts to measure platelet function have, 
until recently, been unsatisfactory. 

“The more recent development of techniques that 
evaluate platelet aggregation has significantly im- 
proved the evaluation of platelet function. These 
techniques allow reproducible and at least semi- 
quantitative assessment of platelet physiology. It 
is significant that this reliably measurable function 
was found to be abnormal in virtually all the 
patients studied herein, with the most common 
abnormality being failure to respond with normal 
aggregation to epinephrine and levarterenol hy- 
drochloride.” (July 17, pg. 273.) 

9. False. “Metastatic choriocarcinoma of the brain 
is a curable lesion. Success requires first a high 
index of suspicion that the patient may have a 
choriocarcinoma. These tumors develop in women 
of childbearing age and commonly produce signs 
and symptoms of subarachnoid hemorrhage, intra- 
cerebral hemorrhage, or brain tumor. Diagnosis 
can be established by radioactive scan of the brain, 
x-ray examinations of the chest, and bio-assay of 
the patient’s urine and cerebrospinal fluid for 
chorionic gonadotropin. Cure is obtained by ex- 
tirpation of the tumor, triple chemotherapy, and 
irradiation of the site of the cerebral metastasis. 
This communication reports three cases of meta- 
static choriocarinoma of the brain in women who 
have been successfully treated, and one unsuccess- 
ful case in a man with metastatic testicular chorio- 
carcinoma.” (July 17, pg. 276, “Abstract”) 

10. True. “The physiologic factors, cause, and therapy 
of lactic acidosis have recently been reviewed in a 
comprehensive paper by Oliva. He concluded that 
severe anemia was probably not a clinical cause of 
lactic acidosis. In Huckabee’s original publication, 
it was found that lactate concentration was ab- 
normal in five patients with severe anemias of 
various causes. Seibert and Ebaugh in a later 
study demonstrated significant excess lactate pro- 
duction in chronically anemic patients with hemo- 
globin values below 6 gm/100 ml. 

“The patient described by Coronato and Cohen 
had become symptomatic, manifesting progressive 
tachypnea and stupor, over a 12-hour period. She 
was subsequently found to have a severe anemia 
(Hemoglobin value, 4.8 gm/100 ml), and elevated 
lactate levels. Improvement occurred within three 
hours after beginning a transfusion of packed 
RBC’s. At the end of eight hours the patient’s 
symptoms had abated and the serum lactate level 
was normal. Further studies confirmed the diag- 
nosis of pernicious anemia. 

“Our patient was first seen in a state of severe 
metabolic acidosis. The unmeasured anion of the 
serum obtained on admission was accounted for 
primarily by the elevated lactate concentration. A 
smaller quantity remained unidentified after an 


extensive laboratory evaluation. The initial pH of 
less than 6.8 is the lowest value we have recorded 
in a surviving patient. 

“Our patient, like that of Coronato and Cohen, 
began to respond shortly after receiving a blood 
transfusion. Thereafter, progressive improvement 
was observed in both the arterial pH and the 
patient’s clinical findings. Within 12 hours, her 
vital signs were stable, she was alert, and the 
acidosis had subsided.” (July 17, pg. 293.) 

11. False. “Previous investigations have shown a 
significant relationship between obesity and hyper- 
tension. The data presented here indicate that this 
represents a relationship between obesity and EH 
only; no such relationship appears to exist between 
obesity and RVH. Patients with hypertension due 
to renal artery stenosis of any etiology are closer, 
on the average, to their actuarially desirable weight 
than are patients with essential hypertension.” 
(July 24, pg. 381.) 

12. (a) a. “Since penicillin G was first instituted as 
therapy for the treatment of early syphilis, there 
has been no detectable change in efficacy. 

b. Tetracycline in a 30-gm dose given in a ten- 
day period compared favorably with other recom- 
mended penicillin schedules. 

c. The base form of erythromycin when adminis- 
tered in a dose of no less than 30 gm (Minimum of 
400 mg/kg of body weight) in a period of ten 
days is an acceptable alternative for penicillin in 
the treatment of early syphilis.” (July 31, pg. 476.) 
Ed. Note: It was interesting to us that 250 mg. of 
erythromycin estolate gives the same blood con- 
centration as 1000 mg of erythromycin base. The 
reason it is not used is the fact that it can produce 
a cholestatic hepatitis. 

13. Ealse. “The herpes-type (HTV) or Epstein-Barr 
virus (EBV) was first discovered in a cell culture 
from a patient with Burkitt’s lymphoma. Seroepi- 
demiologic studies have shown antibody to antigens 
associated with EBV infection to be common in 
normal individuals as well as patients with various 
diseases. The virus has been implicated as etiologic 
in benign and malignant lymphorproliferative dis- 
eases, including infectious mononucleosis and 
Burkitt’s lymphoma. High antibody levels have 
also been associated with an increasing number of 
diseases having disordered lymphoid function, 
which include chronic lymphocytic leukemia, 
Hodgkin’s disease, and sarcoidosis. The virus ap- 
pears to result in a latent infection of lymphocytes 
and possibly other cells.” (pg. 23.) 

14. False. “It is clear that the antibody activity 
against EBV antigens in any of the groups studied 
is not comparable to that shown in other diseases 
with lymphoid dysfunction such as chronic lym- 
phocytic leukemia, Hodgkin’s disease, infectious 
mononucleosis, or sarcoidosis; and there is in- 
sufficient evidence to implicate this virus as 
etiologic in any of the ‘collagen vascular’ or ‘con- 
nective tissue’ diseases studied.” (pg. 27.) 


80 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


15. True. “The present limited investigations in digi- 
talis intoxication show frequent persistence of 
electrocardiographic evidence of intoxication fol- 
lowing decline of levels in the blood to concen- 
trations which, in the steady state, would be con- 
sidered normal maintenance levels.” (pg. 36.) 

16. True. “Death during an asthmatic attack may be 
due to a variety of causes and may take place 
without premonitory signs. Regardless of the im- 
mediate cause of death, the pathological findings of 
extensive plugging of airways, especially bron- 
chioles, with tenacious mucus, edema of bronchial 
walls, and infiltration of bronchial walls by 
eosinophils are almost invariably present. Efficacy 
of treatment is difficult to assess because of the 
lack of a uniform system of grading the severity of 
attacks. . . . Most authors state that the deaths 
reported occurred early in their series before 
treatment principles were established. Sudden 
death while the patient was unattended is widely 
reported. The use of cardiotonic bronchodilator 
drugs during this hypoxic state can result in cardiac 
arrhythmias. Paradoxical reactions from the use 
of these drugs result in increased airway resistance. 
The association of the use of sedative drugs with 
death in status asthmaticus was observed as long 
ago as 1943.” (pg. 40.) 

17. False. “Despite improvement in airway obstruc- 
tion in patients with bronchitis and asthma, many 
observers have reported a fall in Pa 02 following 
the nebulization of isoproterenol and other bron- 
chial dilators. In this study we have also observed 
beneficial effects of bronchial dilators on airway 
obstruction. However, the insignificant fall in 
Pa 02 as well as PaC 02 occurs following nebuliza- 
tion of both the inert material and isoproterenol. 
Further, the fall in Pa02 and PaC02 is followed 
by a return to prenebulization levels by 30 minutes. 
Since the maximal improvement in airway resis- 
tance persists for 30 minutes, it is unlikely that the 
slight postnebulization fall in blood gases is of 
any significance.” (pg. 46). 

18. False. “Certain points concerning the bone pain 
of multiple myeloma can be made as a result of 
this study. (1) The severe back pain, which oc- 
curs in 65% to 75% of patients does not appear 
to be related to old vertebral collapse per se. . . . 

(2) Bone pain does not appear to be related to 
the presence of ‘punched out’ foci of osteolysis or 
of demineralization (i.e., to ‘tumor pressure’). . . . 

(3) Moderate and severe bone pain was invariably 
accompanied by abnormal strontium uptake, and 
the scintigraphic findings preceded roentgeno- 
graphic changes by three to ten (or more) months.” 

19. True. “Radiation therapy is known to afford ex- 
cellent palliation in this disease, and the strontium 
scan is of considerable aid to the therapist in 
setting treatment portals. Two of our patients re- 
ceived a total of four courses of radiation therapy 
to scan-positive, painful areas with a moderate to 
excellent response, although roentgenograms were 


abnormal in only two of the four areas treated. 
Thus, it would appear to be desirable to obtain 
bone scans in symptomatic patients in order to 
provide symptomatic relief by means of radiation 
therapy and, hopefully, to prevent vertebral col- 
lapse or pathologic fracture, as well as to alleviate 
pain.” (pgs. 57-58.) 

20. True. “Sepsis caused by multiple-organisms was 
encountered in drug-users, patients with leukemia 
on chemotherapy, and in a neonate and amnionitis. 
Otherwise, blood cultures containing more than 
one organism were indicative of contamination.” 
(pg. 87.) 

21. False. ‘Tn an attempt to standardize conditions for 
quantitating proteinuria, we examined the effect 
of water loading and intravenous administration of 
furosemide on protein excretion in man. Urine 
volume, protein excretion, and creatinine clearance 
increased in both studies, and there was significant 
correlation between percentage changes in protein 
excretion and creatinine clearance. We recommend 
that protein excretion rate should be determined 
during short periods under standard conditions of 
posture, hydration, and ideally, without interfer- 
ence by drugs.” (pg. 90.) 

22. False. “Our microbiological results confirm the 
findings of others that gram-negative organisms are 
predominant in nosocomial infections and that 
antibiotic treatment or instrumentation, or both, 
results in an increased number of gram-negative 
organisms, as well as in infections due to a greater 
variety of species than found in community- 
acquired infection. 

“As Schneierson has previously reported, there 
is a high percentage of strains resistant to ampicil- 
lin and tetracycline and a very small percentage of 
resistant strains with gentamicin among gram- 
negative organisms. 

“Also, as shown elsewhere, we found that the 
percentage of medium resistant or highly resistant 
strains is higher in the nosocomial as compared to 
the community-acquired strains. However, more 
than half of all the strains isolated in both groups 
are sensitive to most of the drugs used in anti- 
infectious therapy.” (pg. 109.) 

23. (a) “Although three basic, reasonably good means 
of treatment for Graves’ disease with hyperthy- 
roidism are available, considerable differences of 
opinion about the indications for each continue to 
exist. Radioactive iodine has steadily gained 
popularity in the last two decades in view of its 
convenience and effectiveness, but surgery is still 
widely used particularly in younger patients. Anti- 
thyroid drugs are often used only as a first 
therapeutic phase, before a ‘definitive’ mode of 
treatment is utilized. However, it has been shown 
that over 50% of patients treated with antithyroid 
drugs undergo a permanent remission and do not 
seem to develop permanent hypothyroidism. On 
the other hand, 40% to 70% of patients treated 
with surgery or radioactive iodine develop hypo- 


JANUARY, 1973 


81 


Doctor! Here Is Your Special 

to meet with other Tennessee physicians, exchange 
views and influence decisions important to 
the medical profession and health care. 

The 138th Annual Meeting 

TENNESSEE MEDICAL 
ASSOCIATION 

April 11-14, 1973 

MEMPHIS 


An outstanding program will provide you with current 
and valuable information in the fields of . . . 

• CLINICAL MEDICINE • MEDICAL EDUCATION 

• SOCIO-ECONOMIC AFFAIRS 

p.s. Bring your wife to the Annual Meeting! She'll enjoy the 
Woman's Auxiliary convention! 



82 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


thyroidism if a ten-year follow-up period is uti- 
lized. 

“Infiltrative exophthalmos, a serious complica- 
tion of Graves’ disease, rarely improves and may 
have its onset after otherwise successful treatment 
of hyperthyroidism. Subtotal thyroidectomy, anti- 
thyroid drugs, external irradiation of the thyroid, 
and radioactive iodine all have been incriminated 
as the cause of the ophthalmopathy or its de- 
terioration appearing after treatment. However, 
several series of patients with Graves’ disease 
which were treated with antithyroid drugs alone 
did not reveal any case of severe deterioration of 
the ophthalmopathy. Beierwaltes also found that 
progression of ophthalmopathy after treatment 
with antithyroid drugs was less frequent, or less 
marked when present, than after treatment by 
surgical means or with radiation. More recently, 
Astwood reported informally, as a clinical im- 
pression, that progression of ophthalmopathy is 
rare when antithyroid drugs are used to treat 
Graves’ disease. A retrospective study done by 
the same author showed that none of the patients 
treated with thyroid blocking drugs required 
surgical operations on the eyes. However, these 
data have not yet been formally published. Aranow 
and Day arrived at a similar conclusion when 
comparing their series treated with antithyroid 
drugs with other series in the literature where 
radioactive iodine was used.” (pg. 111.) 

24. True. “Although expert opinion on leukemia has 
moved in the direction of a hazard-defense-system 
theory of etiology, the public-health implications 
of this type of theory have not been very widely 
recognized. Thus, the traditional single-factor 
theory of leukemogenesis is commonly used in 
setting “safe” levels for exposure to low-level 
radiation. However, if, as in the simplest hazard- 
defense-system theories, there is a “susceptible” 
subgroup in the general population, the assumption 
of a homogeneous poplulation at risk that is 
implicit in single-factor theories is a dangerous one. 
For “safe” levels to accomplish their purpose, they 
must be set to protect the “susceptible” members of 
the general population, who may be vulnerable to 
dosage levels that may be orders of magnitude 
lower than those that are hazardous to “nonsus- 
ceptible” subjects. Since the “nonsusceptible” 
group constitutes the vast majority of the popu- 
lation, an assumption of homogeneity tends to lead 
to levels that are safe for most persons but fail 
to protect the “susceptible” ones. 

“The hypothesis that there is a “susceptible” sub- 
group in the general population has been supported 
by indirect factual evidence and theoretic argu- 
ments, but it is not easy to develop a clear-cut 
scientific demonstration of the existence of “sus- 
ceptible” subjects. Such a demonstration requires 
the identification of “susceptible” persons on a 
probability basis. In childhood leukemia a number 
of items of information have been suggested as 
relevant to this identification. Most of these are 
items in the medical history of the leukemic 


child or of its mother. However, a formal, objec- 
tive test of the “susceptible” hypothesis requires 
extensive information on medical history and 
exposure to potential hazards on a large series of 
cases of leukemia and of controls representative of 
the general population. Lengthy and expensive 
statistical processing is required to put these data 
in a form suitable for a valid test of the hypothesis. 
Large-scale surveys in England and the United 
States have confirmed the relevance of some of 
the suggested indicators of ‘susceptibility.’ ” (pg. 
107.) 

25. False. “We have thus presented data that in 31 
patients who had an ileostomy and colectomy for 
Crohn’s disease of the colon clinically important, 
x-ray-evident, and (in 21 whose tissues were re- 
viewed) pathologically confirmed recurrent granu- 
lomatous disease of the small bowel developed. 
“Our experience is thus in striking contrast to that 
of the group from the Beth Israel Hospital of 
Boston, who ‘have been unable to find a single 
patient with either granulomatous or ulcerative 
colitis who has had inexorable, progressively more 
proximal spread of disease and nutritional im- 
pairment, as so often happens in postoperative 
regional enteritis.’ Since ileostomy and colectomy 
are considered curative of ulcerative colitis, al- 
though ‘ileostomy dysfunction’ may require re- 
vision on occasion, the distinction between these 
clinical entities should be sharply drawn, and 
their different therapeutic implications recognized. 
“The figure of 46 per cent recurrence after ileos- 
tomy approximates that expected for recurrent 
ileitis proximal to anastomosis after ileocolostomy 
during a similar follow-up period. Thus, it must be 
recognized that Crohn’s disease of the colon can 
recur in the small bowel, with all its classic and 
debilitating features, after ileostomy and extirpa- 
tion of the colonic disease.” (pg. 114.) 

26. False. “Transient neonatal diabetes is a self- 
limiting condition beginning in the immediate 
newborn period and lasting for three to four 
months. It is usually seen in infants who are small 
for gestational age and is characterized by severe 
dehydration, glycosuria and hyperglycemia in the 
absence of ketonemia. Insulin therapy is usually 
essential to keep the blood sugar at normal levels. 
Insulin is known to be present in the fetal pancreas 
as early as 8 to 10 weeks of gestation. How- 
ever, release of insulin from fetal pancreas in 
response to glucose and tolbutamide is poor. At 
term, release of insulin occurs in response to 
hyperglycemia, glucagon, and amino acids, but 
not to tolbutamide. The factors responsible for 
maturation of insulin-releasing mechanisms are 
not known.” (pg. 121.) 

27. True. “The increased susceptibility of patients with 
SS disease to infection may be related to an im- 
mune deficiency state. 

“Although the mechanism of increased severity of 
mycoplasmal infection in patients with SS disease 
is not obvious, this observation may have im- 


JANUARY, 1973 


83 


poitant therapeutic implications. In such cases, 
pulmonary illness characterized by fever, infil- 
trates, and leukocytosis represents a relatively 
common pediatric or medical problem. Although 
the primacy of pneumococcal infection in these 
situations cannot be challenged, the possibility of 
other infecting agents such as M. pneumoniae 
must be considered, even in the presence of pleural 
elfusion and pleuritic pain. 

28. True. “The prevalence of CMV in the milk of 
normal women is relevant to the renewed interest 
in the role of viruses in mammary cancer, and 
should be remembered in studies concerned with 
the detection of viruses or antigens in human 
milk. The possibility of a genuine association of 
CMV with breast cancer should not be dismissed 
without investigation, since other members of the 
herpes group are known to be associated with 
tumors in animals and man.” (pg. 178.) 

29. True. “The curative role of radiotherapy in the 
treatment of localized Hodgkin’s disease has been 
amply demonstrated. Although extended-field and 
total-lmphoid radiation have greately improved 
disease-free survival, initial disease settings that 
include systemic symptoms and disease above and 
below the diaphragm are associated with significant 
recurrence rates. The tumoricidal dose level of 
radiotherapy necessary to eradicate, totally a focus 
of Hodgkin’s disease is known. Since all sites of 
known Hodgkin’s disease are treated with such 
doses of radiotherapy, it is reasonable to assume 
that occult microscopic foci of disease outside of 
treatment fields are responsible for most relapses 
after total-lymphoid radiation.” (pg, 1.) 

30. False. “During the period of our study (August 
1968 to November 1971) disease-free actuarial 
survival was demonstrated to be superior in the 
group receiving sequential radiotherapy and 
chemotherapy. These results are encouraging but 
must be viewed with caution. As shown in Figure 
4, actual survival for the two groups is not yet 
significantly different. Thus, the ability of com- 
bination therapy to cure or to prolong significantly 
the lives of more patients with Hodgkin’s disease 
than radiotherapy alone has not been demonstrated. 
It is possible that all that has been accomplished 
by giving MOPP therapy after radiotherapy is to 
delay the appearance of relapses by administrating 
continued suppressive therapy for 6 to 8 months. 


The fact that disease-free survival was significantly 
different, even when calculated from the end of all 
therapy, diminishes the likelihood of this possi- 
bility. An alternative possibility that is far from 
excluded is that the salvage rate among patients 
who relapse after radiotherapy alone and are 
then treated with MOPP may be high enough to 
offset the apparent initial superiority of the 
sequential therapy with respect to long-term sur- 
vival. 

“For the present, we consider it still premature 
to recommend the general use of total-lymphoid 
radiotherapy plus combination chemotherapy in 
patient with Hodgkin’s disease.” (pgs. 8 & 9.) 
EDITOR’S NOTE: MOPP is the code for combi- 
nation chemotherapy. It indicates nitrogen mus- 
tard, vincristine, procarbazine and prednisone were 
used. 

31. (a). “Deep-seated fungal infections may respond 
favorably to treatment with currently available 
drugs, yet there is need to expand the armamen- 
tarium. Amphotericin B, the principal drug now in 
use, produces adverse effects, such as fever, throm- 
bophlebitis, and renal toxicity, that limit its ef- 
fective use.” (pg. 43, col. 1.) 

32. (B). “The antimicrobial drug, 5-fiuorocytosine, was 
successfully used in systemic infections caused by 
Cryptococcus neoformans, species of Candida, 
Toriilopsis glabrata, and Aspergillus fiimigatus, as 
well as in deep skin infections caused by Phialo- 
phora species. It inhibited disseminated sporotricho- 
sis. Cryptococcal disease showed the greatest 
variability in response to treatment, with relapse 
being common after an initial period of clinical 
improvement. Candidal endocarditis probably 
should not be treated with this drug alone. 

“The drug interferes with nucleic acid metabo- 
lism in various fungal species. As with antineo- 
plastic agents, fungal cells that have incorporated 
5-ffuorocytosine may not die immediately. Mam- 
malian cells apparently do not metabolize the 
drug, 

“Conveniently, the drug can be administered 
orally to outpatients, is relatively nontoxic com- 
pared to amphotericin B, and can be given in full 
therapeutic dose when beginning treatment. It does 
not replace amphotericin B; rather, it expands the 
armamentarium for treatment of systemic fungus 
diseases. Simultaneous use of both drugs may be 
indicated in some patients.” (pg. 48.) 




Dollars Today — 
Doctors Tomorrow 

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Education and Research Foundation 

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84 


JOURNAL OF THE TENNESSEE MEDIOAL ASSOCIATION 



The Placement Service of the Tennessee Medical 
Association is designed to assist both physicians and 
communities and is offered as a public service. Further 
information is available from the Public Service Office 
of TMA, 112 Louise Avenue, Nashville, Tennessee 
37203— phone 327-1451. 


LOCATIONS WANTED 

PSYCHIATRIST, age 41, graduate of Hahnemann 
Medical College of Philadelphia in 1956, wants associ- 
ate or solo practice anywhere in Tennessee. Board 
eligible; presently in institutional type practice. Mar- 
ried. Available February, 1973. LW-814 

• 

GENERAL SURGEON, age 33, graduate of King 
Edward Medical College (Pakistan) in 1962, wants 
solo practice anywhere in Tennessee. Board eligible. 
Single. Available July, 1973. LW-822 

• 

OPHTHALMOLOGIST, age 31, graduate of Bow- 
man Gray School of Medicine in 1967, wants associate 
or solo practice in East Tennessee. Board eligible; pres- 
ently completing military duty. Married. Available 
July, 1973. LW-824 

• 

INTERNIST, age 31, graduate of Vanderbilt Uni- 
versity School of Medicine in 1967, wants associate 
or clinical type practice anywhere in Tennessee. Board 
certified; presently in residency. Married. Available 
July, 1973. LW-826 

• 

INTERNIST, age 29, graduate of Cornell University 
Medical School in 1969, wants clinical, institutional 
or group practice in East Tennessee. Board certified; 
presently in residency. Married. Available July, 1973. 

LW-827 

• 

OPHTHALMOLOGIST, age 30, graduate of the 
University of Pittsburgh School of Medicine in 1967, 
wants associate or clinical practice anywhere in Ten- 
nessee. Board eligible; presently in residency. Married. 
Available Summer of 1973. LW-828 


OB-GYN, age 30, graduate of Teheran Medical 
School (Iran) in 1967, wants associate practice in 
Middle Tennessee. Board eligible; presently in resi- 
dency. Married. Available July, 1973. LW-829 

• 

GENERAL SURGEON, age 32, graduate of the 
University of Santo Tomas in 1964, wants Emergency 
Room practice in East Tennessee. Board eligible; pres- 
ently in institutional type practice. Married Available 
July, 1973. LW-830 

• 

GENERAL SURGEON, age 31, graduate of St. 
Louis University School of Medicine in 1966, wants 
associate or clinical practice in East or Middle Ten- 
nessee. Board eligible; presently in residency. Married. 
Available July, 1973. LW-831 

• 

GENERAL SURGEON, interested in combining 
general surgery and general practice, age 34, graduate 
of Albany Medical College in 1965, wants associate 
practice in Middle Tennessee. Board eligible; presently 
completing military obligation. Married. Available 
Summer of 1973. LW-832 


PHYSICIANS WANTED 

INTERNIST, OBSTETRICIAN, OTOLARYNGOL- 
OGIST, (and/or) OPHTHALMOLOGIST and 
FAMILY PHYSICIAN, needed by specialist group 
with fully accredited private hospital. Located in 
East Tennessee city with metropolitan population of 
50,000 and a fully accredited school system. Salary 
open first year leading to partnership. PW-273 

• 

EMERGENCY ROOM COVERAGE, large hospital 
in Middle Tennessee metropolis is interested in secur- 
ing the services of an Emergency Room team of 
physicians with a guaranteed minimum annual pay- 
ment of $100,000. Physicians would bill for their 
services, hospital provide billing and collection services 
free. ^ ^ PW-299 

FAMILY PHYSICIAN, needed in growing Middle 
Tennessee community. Office space available in new, 
27-bed hospital; well equipped and staffed. Age 30-50. 
Excellent location near recreational water facilities. 

^ PW-307 

EAMILY PHYSICIAN or INTERNIST, splendid 
opportunity to join group of 3 AAFP members. Ro- 
tate night and weekend calls, hospital privilege open 
adjacent to office building. Financial arrangements 
wide open with opportunity to net $2,500 monthly 
first year. Located in West Tennessee town with coun- 
ty population around 30,000. PW-309 

• 

FAMILY PHYSICIAN, needed in West Tennessee 
town near three well equipped hospitals. Office space 
and equipment available. Thriving industry in sur- 
rounding area. ^ PW-316 

FAMILY PHYSICIAN, needed in East Tennessee 
town to form clinical type practice. Large clinic build- 
ing available. Nearest hospital located 20 miles away. 
Good housing, schools, churches and numerous com- 
munity organizations. Industrial and agricultural com- 
munity surrounded by numerous resort areas. PW-333 

• 

EMERGENCY SERVICE DIRECTOR, full time 
position requires interest in administration, teaching 
and patient care. Active service 130,000 visits per 
year. Full house staff coverage; University appoint- 
ment with salary; incentive; and fringe benefits. 

^ PW-335 

OB-GYN, INTERNISTS, CARDIOLOGIST, FAM- 
ILY PHYSICIANS and PEDIATRICIANS, needed in 
East Tennessee town to serve in new 120-bed general 
hospital presently under construction (scheduled for 
completion mid-1973). PW-345 

• 

INDUSTRIAL PHYSICIAN, needed as full-time 
staff physician in East Tennessee with a company 
which manufactures fibers, chemicals and plastics. 
Competitive salary based on experience and qualifi- 
cations; outstanding employee benefit program. Office 
space and equipment available. Occupational medicine 
experience desirable, but not required. PW-349 

• 

EMERGENCY DEPARTMENT PHYSICIAN, 
needed in a 525-bed University affiliated teaching 
hospital in East Tennessee. Faculty status, retirement 
benefits, paid vacation, teaching in FP residency, 
alternate two weeks on duty, minimum guarantee, 
continuing education programs, sub-specialty back-up, 
and a new ED are some of the attractions. PW-350 


JANUARY, 1973 


91 


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Hill Crest Hospital 12 

Hospital Corp. of America, Nashville 33 

Jackson-Madison County General Hospital 37 

Lederle Laboratories 48 

Lilly, Eli & Co 1, 20 

Merck, Sharp & Dohme 10, 11 

Mid-South Medical Association 42 


Mutual Benefit Life Insurance 76 

Ortho Pharmaceutical Corp. 9 

Pharmaceutical Manufacturers Assn 17, 18, 19 

Poythress, Wm. P. Co 93 

Roche Laboratories ... .2, 3, 14, 15, 72, 73, 85, 86, 87, 94 

St. Albans 29 

Searle 46, 47 

Smith, Reed, Thompson & Ellis Co 4 

Stuart Pharmaceuticals 8, 88, 89 

TMA — Aloha Carnival 54 

TMA — Notice to Members 53 

TMA — 138th Annual Meeting 82 

Upjohn Company 13 

Wallace Pharmaceuticals 76 

Warner-Chilcott Laboratories 90 

White Surgical Supply Co 14 

Willingway 5 


92 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



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jOUfIMlI 

OF THE 

TENNESSEE MEDICAL 
ASSOCIATION 

FEBRUARY, 1973 

Vol. 66 No. 2 

Published Monthly By 
Tennessee Medical Association 
Office of Publication, 
112 Louise Avenue 
Nashville, Tenn. 37203 

Second Class Postage Paid at 
Nashville, Tenn. 

TMA OFFICERS 
President 

Wm, T. Satterfield, Sr., M.D. 

1188 Minna Place 
Memphis 38104 

President-Elect 
0. Morse Kochtitzky, M.D. 
2104 West End Ave. 
Nashville 37203 

Chairman, Board of Trustees 
C. Gordon Peerman, Jr., M.D. 
21st & Hayes Medical Bldg. 

Nashville 37203 

EDITORIAL STAFF 

Editor 

John B. Thomison, M.D. 

Managing Editor and 
Business Manager 
Jack E. Ballentine 

TMA EXECUTIVE STAFF 

Executive Director 
Jack E. Ballentine 

Assistant Executive Director 
L. Hadley Williams 

Executive Assistant 
John M. Westenberger 

Executive Assistant 
William V. Wallace 

The Journal of the Tennessee 
Medical Association 
112 Louise Ave. 
Nashville, Tennessee 37203 

Published monthly under the direction of 
the Board of Trustees for and by members 
of The Tennessee Medical Association, a 
nonprofit organization, with a definite 
membership for scientific and educational 

purposes. 

Subscription $9.00 per year to non- 
members; single copy, 75 cents. Payment 
of Tennessee Medical Association 
membership dues includes the subscription 
price of this Journal. 
Devoted to the interests of the medical 
profession of Tennessee. This association 
does not officially endorse opinions 
presented in different papers published 
herein. Copyright, 1973 by the Journal of 
the Tennessee Medical Association. 
Advertisers must conform to policies and 
regulations established by the Board of 
Trustees of the 
Tennessee Medical Association. 


cenlenl/ 

SCIENTIFIC SECTION 

115 The Responsibilities of a Surgeon, Horace T. Lavely, Jr., M.D. 

118 Implied Consent, J. T. Francisco, M.D. 

121 Eating Fresh Coffee Grounds: Psychoneurosis or Sub-Clinical Pellagra, 

David F. Moore, M.D. 

124 Clinicopathologic Conference 

128 EKG of the Month 

130 Self-Evaluation Quiz 

132 Topics in Nuclear Medicine 

134 From the Regional Medical Programs 

154 Continuing Education Opportunities 

157 From Tennessee Department of Public Health 

NEWS AND ORGANIZATIONAL SECTION 

143 President’s Page 

144 Editorials 
146 In Memoriam 
146 New Members 

146 Programs and News of Medical Societies 

147 National News 

151 Medical News in Tennessee 

152 Personal News 
154 Announcements 
166 Special Item 

189 Placement Service 

190 Index to Advertisers 

Contents listed in CURRENT CONTENTS/CLINICAL PRACTICE 
of The Institute for Scientific Information 


INSTRUCTIONS TO CONTRIBUTORS 

Manuscripts submitted for consideration for publication in the JOURNAL 
OF THE TENNESSEE MEDICAL ASSOCIATION should be addressed to 
the Editor, John B. Thomison, M.D., P.O. Box 70, Nashville, Tennessee 
37202. 

Manuscripts must be typewritten on one side of letterweight paper. 
Either double or triple spacing and wide margins must be provided to 
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Bibliographic references should not exceed twenty in number docu- 
menting key publications. They should appear at the end of the paper. 
The bibliographic references must conform to the style used in the 
American Medical Association publications, as, — Alais, FG: What is Known 
About it, J. Tennessee M. A., 35:132, 1950. 

Illustrations should be numbered and identified with the author’s name. 
The editor will determine the number, if any, of illustrations to be used 
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author. They will not be returned unless specifically requested. 

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a reprint cost schedule will be forwarded upon request. 


jOUflKlI 

OF THE TENNESSEE MEDICAL ASSOCIATION 

OWNED AND PUBLISHED BY THE ASSOCIATION 

FEBRUARY, 1973 
VOLUME 66, NO. 2 


The Responsibilities 
Of a Surgeon 

HORACE T. LAVELY, JR., M.D. 

In the years in which I have been a member 
of this society, I have heard many outstanding 
presidential addresses. They have covered most 
aspects of medical history and surgical philos- 
ophy. As I reflected on the choice of a topic 
for this occasion, it seemed that there was little 
that I could express which had not already been 
said. Nevertheless, I thought I would share with 
you this evening some of my thoughts on the 
responsibilities of a surgeon, and examine with 
you some of the reasons why this is such a 
trying, yet rewarding, profession. In order to do 
this, we must have some understanding of what 
constitutes a surgeon. How does he come about? 
What are his characteristics, attributes, deficien- 
cies, and goals? He does not, like the goddess 
Athena, spring full grown from his father’s fore- 
head. 

No other profession has more romantic at- 
traction than the practice of surgery. Movies, 
and particularly television, have done much to 
glamorize it. The high point of many a drama 
is played out under the glare of the operating 
room lights. Yet, with all its excitement and 
glamor, surgery is the most demanding of all 
the medical specialties, the most highly restric- 
tive, and in many ways, the most difficult to 
achieve. 

Dr. W. D. Haggard, one of Nashville’s 
pioneer surgeons, called surgery the Queen of 
the Arts, and described it as the skilled use of 
the hands at the behest of the brain, applied to 
wound and disease in a service such as the 
angels. If this is true, how can the practitioners 
of this art be less than regal? On the other 
side of the coin, a current author has described 

* Presidential Address, Nashville Surgical Society, 
November 10, 1972. 


the surgeon as basically a cold man, contemptu- 
ous of people in medicine outside his specialty, 
and jealous of those within it. Hopefully, Dr. 
Haggard’s model is nearer to the truth, but a 
closer examination may tell us why this latter 
viewpoint is prevalent, and what we can do to 
ameliorate it. 

At the risk of sounding immodest, I feel that 
surgeons do possess certain characteristics and 
traits which set them apart. Certainly they are 
unique in many ways: the type of work which 
they do, the kind of training they require, the 
time, money, and labor invested in preparing 
themselves, and the variety of activities in which 
they may be involved. 

What sort of individual then are we likely to 
see migrating to this demanding specialty? It 
goes without saying that he must be intelligent. 
No one can absorb the amount of material 
needed, apply the proper reasoning, make the 
necessary decisions, sustain the incidental inter- 
personal relationships and carry the tasks to 
their conclusion without this trait. 

A surgeon must be aggressive. Frequently he 
is faced with a situation in which procrastina- 
tion may be dangerous, even fatal. He must 
then with all available information take some 
decisive action. He cannot, like some of his 
medical confreres, order another battery of tests 
and await developments. He must take the bull 
by the horns and make irrevocable decisions. 
This necessarily means that he must have a little 
of the riverboat gambler’s instincts, and, like 
the gambler, to survive, he must be right. 

Still, this intelligence and decisiveness must 
be tempered by conscience, which, while not 
listed first, has been called the first great re- 
quirement of the surgeon. Furthermore, judg- 
ment goes hand in hand with conscience, and 
while it is difficult to acquire, it is imperative 
that it be exercised. 

It has been said that good judgment is ac- 
quired by experience, and that experience is 
acquired by poor judgment. However facetious 
this observation, it does contain a germ of truth. 


FEBRUARY, 1973 


115 


and it emphasizes the fact that nothing is more 
important to the complete surgeon than the 
exercise of judgment, and however he acquires 
it, this is what he stands or falls on. 

By definition a surgeon is one who works 
with his hands or with instruments in the treat- 
ment of disease or deformity. While his work 
may vary greatly, depending upon the particular 
surgical specialty he has chosen, still this ap- 
proach to the treatment of disease sets him 
apart from the rest of the practitioners of 
medicine. 

His education is lengthy and arduous, usually 
consuming 13 to 17 years of preparation, and 
even at the completion of this prescribed period 
of education and training he can never cease to 
be a student. Whether it is the dog laboratory, 
the autopsy room, specialty group meetings, 
reading medical literature, or in conversation 
with his colleagues, he constantly seeks to en- 
large and improve his knowledge as, indeed, 
he must, since without continuing education for 
10 years, a physician will find himself with only 
25% of his knowledge up to date, for it has been 
estimated that the life of medical knowledge is 
only 5 years. In a field in which changes are 
as rapid and advances so common as surgery, 
even this estimate may be too conservative. 

What then must this intelligent, educated, 
decisive, conscientious individual do in the pur- 
suit of his chosen specialty to discharge his 
responsibility? Indeed, what are his responsi- 
bilities? There are many responsibilities inherent 
in being a doctor. While obviously there is 
overlapping in many areas, for the sake of dis- 
cussion we can consider his responsibility to 
his patients, to his profession and to himself. 
Many of these are enlarged or enhanced in a 
special way by the practice of surgery. 

A surgeon’s primary responsibility is to his 
patients. This relationship is the basic one in 
the medical system which has evolved in this 
country, and while from time to time we may 
be guilty of practices which undermine it, we 
should strive to maintain and even improve 
this relationship. 

It is, of course, imperative that the surgeon 
bring to bear all of his talents in the treatment 
of each patient. He must exercise such skill and 
judgment that there can be no doubt that the 
correct course of management has been carried 
out. This responsibility in itself is an awesome 
one which is implied in his contact with each 
and every patient. 

116 


In no other field of human endeavor is this 
insistence on perfection manifested to such a 
degree. Each individual physician is expected 
to perform 100% of the time with such degree 
of exactitude that no error in judgment or 
technique will occur. While we all know this 
is far beyond any human capacity, still this 
expectation implied in the relationship with 
each patient is like the sword of Damocles 
hanging over him. This burden of infallibility 
which he carries is greater for the surgeon, for 
while his actions may be more bold and dramatic 
in his attempts to restore life and limb, still if 
something goes awry it is more obvious. 

A surgeon must constantly decide whether a 
given problem falls within the scope of his train- 
ing and experience, and if not he must be 
certain that such training, experience, and skill 
are brought to bear on that patient. 

There is one area of doctor-patient relation- 
ships where physicians in general are probably 
deficient. This is in the area of communication. 
This is particularly unfortunate in the case of 
surgeons because of the character of the proce- 
dures which are performed and the consequences 
resulting from them. 

In my experience this failure to communicate 
with the patient and his family is the major 
complaint which patients and hospital personnel 
have about surgeons. It is also a major cause 
of psychological trauma which may be quite 
disruptive, and is probably a significant factor in 
the institution of legal proceedings. 

There is really no excuse for this shortcoming. 
We all know that no matter how well planned 
or executed, some procedures are fraught with 
unfortunate complications and we accept this 
as a calculated risk. Compared with the com- 
plexity of the procedures which we must per- 
form it is a simple matter to sit down and talk 
with a patient and his family about his condi- 
tion, what it is, what we are planning to do 
about it, and what he can expect as a result of 
this treatment. This responsibility for communi- 
cation is particularly important postoperatively. 
I believe that any surgeon who operates on a 
patient has the obligation to meet face to face 
with the patient’s family, allay their anxiety, and 
give them a reasonable idea of what was found, 
what was done, and what to expect. The excuse 
that we are too busy is simply not valid. If we 
are too busy for this essential part of a patient’s 
management, we should not be doing it at all. 
Let’s remember that patients — and their families 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


— are people too, and as Ralph Waldo Emerson 
said: “Life is not so short but that there is 

always time enough for courtesy.” 

Furthermore, in talking with a patient or his 
family we must be certain that we use language 
which he can understand. While the public is 
much more medically aware than it once was, 
they still do not understand a good many of the 
technical terms which we use, and it is our 
obligation to talk in terms which they under- 
stand. 

Let us turn now to the surgeon’s responsibility 
to his profession. First and foremost he is 
charged with the obligation of sharing his knowl- 
edge with others. This duty is as old as med- 
icine itself and is spelled out in the Hippocratic 
Oath. 

This willingness to teach and share informa- 
tion is one of the qualities which sets medicine 
apart from other businesses and professions. 
These are no patents, no secret formulas under 
lock and key, no new models. Everything is 
out in the open for anyone who is willing to 
learn. Here too, the surgeon by the nature of 
his activities is in a position to teach at every 
turn. In the examining room, in the operating 
room, or when making rounds, no patient is 
so routine, no procedure so simple, that some- 
thing cannot be learned from it if we will just 
take the time and the trouble to do it. 

One of the main criticisms which is leveled at 
the medical profession is that they close ranks 
and protect each other, even when they are at 
fault. While in an abstract sense this trait may 
be admirable, and, in fact, its application may 
be exaggerated, still we do have a responsibility 
in this area which is probably too often ignored. 
Let’s face it, we are all human beings and 
whether we are doctors, lawyers, college pro- 
fessors, or business men there will be a few 
bad apples in the barrel. It is our responsibility 
to weed them out. Again, because of the nature 
of surgery and its potential for benefit by cor- 
rect application, we also have the tremendous 
potential for harm if incorrectly practiced. 

This responsibility for self policing, which 
also involves peer review and continuing educa- 
tion, is a delicate one. Nevertheless it is more 
and more in the forefront and we must dis- 
charge this responsibility ourselves if we are to 


maintain the independence which we cherish. 

We live today in a changing world with 
changing moral values, changing social philos- 
ophy, and accelerated technological advances. 
As a result of these changes, we, as physicians, 
are faced with new problems which require new 
solutions: threats of legal liability, decisions as 
to when death occurs, medical care for the poor 
and disfranchised, management of catastrophic 
illness, health care delivery — these and count- 
less others constantly call for revisions in our 
traditional approach to medical problems. While 
many of these problems are of an ethical nature 
and must be resolved on an individual basis, 
many involve the medical profession as a whole 
and can best be handled by our duly elected 
representatives. 

From time to time I hear some of my col- 
leagues making disparaging remarks about the 
Nashville Academy of Medicine, the TMA or 
the AMA. This is like cutting off your nose 
to spite your face. Let’s face it, we are the 
NAM, TMA and AMA, and if they do not 
reflect our wishes and best interests it is our 
responsibility to get involved and do something 
constructive about it. 

Finally, a surgeon has a responsibility to 
himself. I think it was Polonius who said: “To 
thine own self be true and it follows as the 
night the day thou canst not then be false 
to any man.” A surgeon must be certain 
that he acquires the necessary knowledge and 
skill to carry out the procedures he embarks on. 
He must maintain this knowledge and skill at a 
high level. He must be constantly alert to the 
ethical implications of his actions. 

Lastly he must develop and maintain a frame 
of mind which allows him to survive psycholog- 
ically. Sir William Osier has called this 
aequanimitas and defines it as the ability to 
bear with composure the misfortunes of others. 
He must be able to react with the proper com- 
bination of concern and detachment in every 
situation. He cannot take his problems home 
with him at night if he is to retain the physical 
and mental acuity required for the performance 
of his task. He cannot allow the exhilaration 
of success or the despair of failure to alter his 
reactions. 

104 20th Ave. No. 

Nashville, Tenn. 37203 


FEBRUARY, 1973 


117 


Implied Consent 

Methods and Results — State of Tennessee, 1971 


The license to drive a motor vehicle in the 
State of Tennessee is presently considered to be 
a privilege and not a right. This determination 
was made by the passage of what is known as 
the Implied Consent Law (1969) for the State 
of Tennessee. The scientific basis for this law 
has been established for many years. The statis- 
tics from various sections of the country have 
well documented the fact that in fatal traffic 
accidents, alcohol is present in the fatality ap- 
proximately 50% of the time.^ It is considered 
likely that if these studies were extended to 
include the responsible party for the fatal traffic 
accident an even greater percentage would have 
alcohol present.^ 

The ultimate stimulus for the passage of this 
state law came from the establishment of Fed- 
eral Standards requiring each state to have an 
Implied Consent Law and a prohibition for 
driving alcohol level of 0.10% in the blood. 
The degree of enforcement of this law varies 
from state to state and from region to region 
within the state. The reasons for this are 
legion but it appears that few people believe 
that a level of .10 of alcohol represents a valid 
level for driving prohibition. The medical facts 
however are clear. Everyone, regardless of 
previous drinking experience, ability, physique, 
or state of nutrition has at least two of his 
faculties affected when his blood alcohol level 
reaches 0.10%: There is alteration in judgment 
and prolongation of reaction time. This does 
not mean that the driver who is under the in- 
fluence of alcohol has a slower reaction time 
than every other driver on the road. It merely 
means that alcohol has altered his reaction 
time compared to his non-drinking driving 
ability. 

The Tennessee Department of Public Health 
has engaged in a series of laboratory develop- 
ments so that laboratories may be strategically 
placed throughout the State of Tennessee to as- 
sist in the determination of the alcohol level 
of the drinking driver. This paper summarizes 
the laboratory development and the results of 

* Professor of Pathology, University of Tennessee, 
Chief Medical Examiner — ^Tennessee. 

118 


J. T. FRANCISCO, M.D.* 

tests performed by these laboratories during the 
year 1971. 

ALCOHOL 

Before giving the figures for these labora- 
tories it is well to briefly review the pharma- 
cology of alcohol. Alcohol is rapidly absorbed 
from the small intestine but is first absorbed 
from the stomach to a lesser extent. Within 
fifteen minutes following a drink, alcohol is 
detectable in the blood. Alcohol is distributed 
rapidly, following its absorption into the blood, 
to all organs in the body. The ratio of this 
distribution is a function of the water content 
of the various tissues and organs of the body. 
Certain organs therefore contain greater abso- 
lute amounts of alcohol than others, but once 
alcohol has reached equilibrium within the 
body there is a constant ratio that is established 
for alcohol. This ratio is based upon the unit 
value of blood as compared to that in all 
other organs of the body. Typical ratios are 
as follows: Blood/brain 1 to 1. Blood/urine 
1 to 1.3. Blood/breath 1 to 2100. A knowl- 
edge of these ratios and their scientific validity 
is the feature that allows a breath determi- 
nation of alcohol to be valid in determining the 
blood alcohol level. Alcohol is primarily me- 
tabolized by the liver, 90% of the alcohol in- 
gested being metabolized in this manner. The 
remaining 10% is excreted in the breath and 
various body secretions. Approximately 6% 
is excreted in the urine and approximately 1% 
in the expired breath. After alcohol reaches 
equilibrium in the body and after the maximum 
absorption has occurred, alcohol is metab- 
olized at a rather constant rate, reflected in 
a blood alcohol level which will fall at a rate 
of somewhere between 0.01 and 0.02 units 
per hour. Stated in another way, if a person 
at any given time has a blood alcohol level 
of 0.10% then he will have a negative blood 
alcohol level between five and ten hours later. 
As a general rule, the peak blood level will 
be attained between 45 minutes and 1 hour 
and 15 minutes after a person has consumed 
his last drink of alcohol. 

The history of passage of the Implied Con- 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


sent Law in the State of Tennessee is somewhat 
stormy, probably because most legislators be- 
lieve that it is possible for two drinks (2 cans 
of beer) to be sufficient to produce in some 
people a blood alcohol concentration of 0.10%. 
This belief is shared by many physicians. From 
a physiologic, pharmacologic and biological 
standpoint, it is an absolute impossibility for a 
person to consume two 12 oz. cans of beer 
and attain a blood alcohol concentration of 

0.10%. This fantasy is based upon the story 
often told by the accused when arrested, tested, 
and charged, that he drank only two beers. 

With the final passage of this law several 
amendments have been necessary in order to 
allow equitable and fair application to all mem- 
bers of society. These amendments have been 
designed to allow for maximum enforcement, 
at the same time protecting the rights of the 
accused. The present law reads as follows: 
“Any physician, registered nurse, clinical lab- 
oratory technologist, or clinical laboratory tech- 
nician who acting at the written request of a 
law enforcement officer, withdraws blood from 
a person for the purpose of making such (blood 
alcohol) tests shall not incur any civil or crim- 
inal liability as may result from a negligence 
of the person so withdrawing.” This segment 
of the law protects the person when acting 
under proper request from having any criminal 
charges brought against him. The law further 
proceeds to state “neither shall . . . incur, ex- 
cept for negligence, any civil or criminal lia- 
bility as a result of the act of withdrawing 
blood from any person submitting thereto.” 
The present procedure is established by the 
Department of Public Health provides that 
once the specimen is withdrawn, it is taken by 
the law enforcement officer to the nearest lab- 
oratory providing this determination. This lab- 
oratory must be a laboratory under the super- 
vision of the Chief Medical Examiner or an 
assistant chief medical examiner. Once the 
alcohol analysis has been determined, the 
medical examiner will execute a certificate 
which gives pertinent data and the result of 
the analysis. This certificate when duly attested 
by the responsible parties is admissible as evi- 
dence in any court in the State. 

METHODS OF ANALYSIS 

A series of regional laboratories were es- 
tablished 

1 . To provide maximum versatility to 


enforcement in alcohol analysis; 

2. To provide close liason between law 
enforcement and the laboratory providing 
the analysis; and 

3. To provide a training vehicle whereby 
laboratory personnel can offer instruction to 
various law enforcement agencies in the 
methods of collection, procedures of anal- 
ysis and proper interpretation of the alco- 
hol results. 

The methods for alcohol analysis are numer- 
ous. The types of specimens that may be avail- 
able for alcohol analysis are also numerous. 
The law enforcement officer may choose to 
collect blood, breath or urine and each must 
be handled somewhat differently. The various 
methods available for alcohol analysis include 
colorimetric, physical, or enzymatic. The pres- 
ent method of analysis by the Tennessee De- 
partment of Public Health is a physical means 
using gas chromatography as basic instrumen- 
tation. Law enforcement also has an option 
of using what is identified here as “in-house 
breath testing equipment.” This equipment 
comes under various trade names of which 
the Breathalyzer and Intoximeter are the most 
commonly used instruments. They are valuable, 
reliable and accurate means of determining the 
blood alcohol level if properly maintained and 
supervised. The use of these instruments 
suffers from the same drawback as the use of 
any instrument: it must be maintained and stan- 
dardized if the results are to be accurate. Lab- 
oratory personnel at the regional forensic 
science laboratories are fully trained and capa- 
ble of providing this kind of supervision. In 
addition to this problem the law enforcement 
officer will be called upon to testify regarding 
his results and their validity at the subsequent 
trial. The capacity of the officer to under- 
stand the principles involved, to clearly present 
these principles and their results become crucial 
in the subsequent prosecution of this case. The 
forensic science laboratory personnel carry out 
an active training program, offering their ser- 
vices to law enforcement agencies so that the 
law enforcement officer may be fully acquainted 
with the problems involved in presenting his 
testimony. 

RESULTS 

The total number of alcohol tests performed 
in the State of Tennessee during the year 1971 
was 9,240. Of these 27% were analyzed in the 
counties having “in-house breath testing equip- 


FEBRUARY, 1973 


119 


Alcohol Test and Troffio by County 1971 



ment.” The remainder were analyzed in the 
regional forensic science laboratories. During 
this time there was at least one specimen ana- 
lyzed for every county of the State of Ten- 
nessee. The distribution and number is shown 
in Figure 1. Of the group analyzed 13% were 
either negative or less than .05. Ten percent 
were between .05 and .09. The remaining 
percentage was greater than .10. 

DISCUSSION 

There are no reliable national figures avail- 
able with which to compare the total number 
of tests in the State of Tennessee in order to 
determine the total number of tests that should 
have been performed. It can be estimated that 
this figure of slightly over 9,000 is probably 
less than the total number that should be 
tested on the streets and highways of this state. 
It is the responsibility of each county medical 
examiner to obtain a blood or urine specimen 
from each fatal traffic accident that he investi- 
gates if the fatality is older than 12 years or 
if death has occurred within 12 hours of the 
accident. An assessment of these results in 
the state of Tennessee indicate that only in 
approximately 75% of the cases the medical 
examiners are complying with this regulation 
by submitting a specimen for analysis. 

The law allows a suspect to refuse to sub- 


mit to an alcohol test. If he does so, however, 
the law provides that his license may be re- 
voked for a period of six months. The harsh- 
ness of this penalty may seem excessive to 
some. The physicians of the state have a 
responsibility to be aware of the medical facts 
surrounding the drinking driver and to make 
these facts known in his community. Without 
a knowledge of the high incidence of alcohol 
in traffic fatalities Ihe public support for this 
law will not be great. Without this kind of 
enforcement there is no convenient, reliable or 
effective means presently available to reduce 
the annual fatalities occurring on the roads, 
streets and highways of this state. The only 
other means would be a massive public edu- 
cation program, so that the driver who chooses 
to drink, chooses not to drive. Until such a 
program is effected, adequate, stringent, and 
uniform law inforcement appears to be the 
only conceivable means by which the annual 
fatality rate due to traffic accidents may be 
reduced in the State of Tennessee. 

858 Madison Ave. 

Memphis, 38103 

REFERENCES 

1. American Medical Association: Alcohol and the 
Impaired Driver, 1970. 

2. Francisco, J.T.: Unpublished Data. 


120 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Eating Fresh Coffee Grounds: 
Psyehoneurosis or Sub-Clinieal Pellagra 

DAVID F. MOORE, M.D. 


REPORT OF A CASE 

The patient, a thirty-five year old married 
white female from the southern U. S., was 
referred for psychiatric consultation in April, 
1967. Her husband was fifty-three years of 
age, they had been married 11 years, and it 
was the second marriage for each. She had 
been under medical care for over fifteen years 
for various somatic complaints and “nervous- 
ness.” She had had an appendectomy when 
she was young and recently had an “abdominal 
operation.” 

The patient complained of abdominal pain, 
back pain, and dysuria. She had decreased 
libido according to her husband. She was oc- 
casionally suspicious of her husband, who was 
a traveling salesman, but he denied any infi- 
delity and said that he was not suspicious of 
his wife. His wife would scream and yell when 
there was an argument at home, and recently 
her emotional outbursts were becoming more 
frequent. He had no complaints regarding their 
sexual relations. He described himself as a 
self-made man, who had worked seventeen 
years with one company with several promo- 
tions, and felt that there was no reason for his 
wife’s feeling that he was a failure. 

The patient had fears and guilt feelings, with 
a possible reaction formation expressed through 
her work in the church. She taught a Bible 
class for adults and was very strict regarding 
her religious beliefs. The husband usually stayed 
home on Sundays to take care of the baby. 

MEDICAL HISTORY 

Reports from other physicians over the past 
ten years revealed that the patient was allergic 
to codeine but there was no known reason for 
her other occasional skin rashes. She had had 
vague and various gastrointestinal and urinary 
complaints. She was described as being neu- 
rotic, and as having decreased sexual interest. 
Her medical records from 1957 to the present 
revealed that she had complained of low back 
pain, without history of trauma, which became 
worse after eating and with bowel movements. 
At first, physical examinations were within 


normal limits, but later a right tubo-ovarian 
mass was palpated, which was 3 cm. in size 
and when palpated produced low back pain. 
She was hospitalized in 1958, and complete 
medical and laboratory tests, at that time, in- 
cluding GI series and IVP, were reported with- 
in normal limits. In March, 1966, she had a 
recurrence of right lower guadrant pain, which 
was relieved by rest. She was readmitted to 
the hospital, and again all findings were within 
normal limits. Three weeks later, she had more 
severe right lower quadrant pain, aggravated 
by walking, which radiated to the back, which 
was considered to be due to adhesions sec- 
ondary to her appendectomy. After several 
weeks nausea and vomiting supervened, plus 
vaginal bleeding, and she was readmitted to 
the hospital for an exploratory laparotomy, 
which revealed a redundant cecum. The pain 
did not recur and she was discharged from 
the hospital. 

NEURO-PSYCHIATRIC EVALUATION 

The patient expressed feelings of insecurity, 
death wishes for her mother and guilt feelings. 
Emotionally she felt close to her father, but 
there was considerable ambivalence. She re- 
emphasized her participation and interest in the 
church. She indicated that her husband con- 
sidered her unfaithful and that he doubted if 
their first child was legitimate by her first 
husband. 

The psychopathology and dynamics were 
compatible with a chronic anxiety reaction and 
associated feelings of depression. There were 
suspicions and paranoid ideations as she de- 
scribed the family relationship. When her hus- 
band was confronted with her accusations, he 
stated, “she exaggerates and feels things exist 
which do not exist.” They have a teenage 
daughter with a hearing defect, and both the 
patient and her husband cooperated in obtain- 
ing aid for her. The patient at this time was 
given Phenothiazine, 25 mgm., b.i.d. 

In April, 1967, the patient’s complaints be- 
came more severe, and she was admitted to 
Wm. F. Bowld Hospital. Findings were com- 


FEBRUARY, 1973 


121 


patible with anxiety and depression. Her labora- 
tory and physical findings were within normal 
limits. She responded to psychotherapy and 
chemotherapy, though mild complaints persisted, 
and she was discharged to out-patient status. 

When asked to describe in complete detail 
an average day, she mentioned that for 15 
years she had been eating whole coffee beans 
and ground coffee, as well as drinking three to 
four cups of coffee per day. With pregnancies, 
she would eat as much as one pound of coffee 
per week. Consultations with University of 
Tennessee Departments of Pharmacy and 
Pharmacognacy suggested a niacin deficiency 
which was being masked by the ingestion of 
coffee, and a clinical diagnosis of pellagra 
was made. 

Tranquilizers were discontinued, and her 
medication was changed to 500 mgm. of nico- 
tinic acid per day. After three days her symp- 
toms cleared. A later examination showed no 
evidence of anxiety, depression, or somatic 
complaints, even with added family stress. Her 
appetite increased, and after three days, she 
no longer craved coffee. After four months, 
she gained ten pounds and was asymptomatic 
on a maintenance dose of 100 mgm. of nico- 
tinic acid per day. 

In May, 1968, she discontinued the nicotinic 
acid medication and exacerbation of her previ-, 
ous symptoms recurred. Her medication was 
reinstituted, and symptoms were again relieved. 

In August, 1968, the patient still felt fine and 
was continuing with the nicotinic acid as pre- 
scribed. She moved to another state and a 
letter from her, April 1972, stated she was still 
asymptomatic and again active in church work. 

REVIEW OF PELLAGRA 

The United States Public Health Department 
estimates that there are four hundred thousand 
cases of pellagra annually in the USA. Ap- 
proximately ten per cent of the patients admit- 
ted to psychiatric institutions in the southern 
part of the United States have pellagra. 

Pellagra is caused primarily by a deficiency, 
specifically, of niacin (nicotinic acid),^’® 
which may arise from dietary deficiency or 
from an impairment of absorption because of 
altered gastrointestinal function.® In some 
cases, the requirement for anti-pellagric sub- 
stances may be in excess of what is supplied 
by the diet.^*^ 

122 


SYMPTOMATOLOGY 

Predisposing factors may play a role in the 
pathogenesis of this disease. Often patients 
complain of fatigue, insomnia, loss of teeth, in- 
fections, food idiosyncrasies, and difficulty in 
the metabolic utilization of food. The marked 
improvement and prompt response in many 
pellagrins who receive intensive appropriate 
dietary treatment leaves no doubt that this dis- 
ease is associated with a dietary deficiency. 
Pellagra dermititis is not always present but may 
be shown as symmetrical lesions on any por- 
tion of the body. When present, the eruption 
is most common over places of irritation such 
as the hands, wrists, elbows, neck, under the 
breasts, knees and feet, and in the perianal 
region. 

The alimentary tract is frequently involved, 
and there may be diarrhea with or without 
abdominal pain or discomfort, which when pres- 
ent is usually more severe after a large meal. 
Nervousness, lack of sleep, headaches, dizziness, 
and muscular weakness are frequent. Pellagrins 
are subject to periods of mental depression and 
apprehension, and unless properly treated, sec- 
ondary psychotic symptoms may appear, such 
as hallucinations, delirium, disorientation, and 
other mental aberrations. Genito-urinary symp- 
toms, primarily dysuria, are frequent. Libido 
is often decreased, and in women there is fre- 
quent vaginitis. Menstruation may be scanty or 
absent.^ 

Some believe that most mental diseases are 
molecular diseases, the result of a biochemical 
abnormality in the human body. The mind is a 
manifestation of the structure of the brain, an 
electrical oscillation in the brain supported by 
its material structure. The mind can be made 
abnormal by an abnormality in the chemical 
structure of the brain itself, which is usually 
hereditary in character, though sometimes 
caused by an abnormality in the environment. 
The mental manifestations of Pellagra can be 
relieved by correcting the molecular abnormal- 
ity that produces them.^^ 

SUMMARY 

This is a case report of sub-clinical pellagra. 
The usual symptomatology was masked by a 
craving of the patient which caused her to eat 
coffee, which contains considerable amounts of 
niacin. 

The presence of unrecognized mild pellagra 
leads to numerous complaints that are at times 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


regarded as neurotic and probably psychogenic. 

5000 Poplar Ave., Suite F 
Memphis, Tenn. 38117 

ACKNOWLEDGEMENTS 

1. William Swafford, M.D., Chairman and Professor, 
University of Tennessee, Department of Pharmacy. 

2. Elmore Taylor, M.D., Chairman and Professor, 
University of Tennessee, Department of Pharmacog- 
nosy. 

3. P. J. Sparer, M.D., Professor of Psychiatry and 
Preventive Medicine, University of Tennessee. 

REFERENCES 

1. Proc Soc Exptl Biol and Med, 102, #3, 579, 
(1959). 

2. Chick, H: Current Theories of the Aetiology of 
Pellagra. Lancet, 2:341, (1933). 

3. Goldberg, J: Pellagra — Its Nature and Preven- 
tion. United States Public Health Report Number 
1174, (1927). 


4. Harris, S: Clinical Pellagra. The C. V. Mosby 
Co., St. Louis, (1941). 

5. Jolliffe, N, McLester, JS, and Sherman, HC: The 
Prevalence of Malnutrition. JAMA, 188:944, (1942). 

6. Sebrell, WH: Table Showing the Pellagra- 

preventive Value of Various Foods. United States 
Public Health Report Number 1632, (1934). 

7. Spies, TD: The Treatment of Pellagra, JAMA, 
104:1377, (1935); 111:584, (1938). 

8. Turner, R: Pellagra Associated with Organic 

Disease of the Gastrointestinal Tract. Amer J Tropical 
Med, 9:129, (1929). 

9. Youmans, JB: Nutritional Deficiencies. J. B. 

Lippincott Company, (1941). 

10. Garrison, W: The Great Pellagra Mystery. 

Today’s Health, AMA, p. 59, Feb. (1968). 

11. Documenta Geigy, “Scientific Tables,” 6th Edi- 
tion, p.513 (1962). 

12. Pharmacognosy, Gathercol and Wirth, 2nd 
Edition, p. 609. 

13. United States Dispensatory, La and Febiger, 
22nd Edition, p. 1331. 

14. Rinkel, M: Biological Treatment of Mental Ill- 
ness. P.32, 56-57, (1966). 


SAINT 

ALBANS 

PSYCHIATRIC HOSPITAL 

Radford, Virginia 


STAFF: 

James P. King, M.D. 

William D. Keck, M.D. 

Morgan E. Scott, M.D. 

David S. Sprague, M.D. 

Edward E. Cale, M.D. 

Delano W. Bolter, M.D. 

Terkild 

Vinding, M.D. 

Clinical Psychology: 
Thomas C. Camp, Ph.D. 
Carl McGraw, Ph.D. 

Don Phillips, Administrator 

George K. White 
Asst. Administrator 


FEBRUARY, 1973 


123 


dinicopcilliolo^ic 

confeience 


Superior Sulcus Tumor* 

Present Illness: This 59-year-old white male carpen- 
ter entered the VA Hospital for the ninth time because 
of chest pain for the past 14 months. The pain, lo- 
cated in the left anterior chest and radiating through 
to the back and left arm along the ulnar aspect to 
the 4th and 5th fingers, had been constant, and was 
not relieved by nitroglycerin. It had been worse in 
the past few weeks and had kept him awake, though 
“shot” by his local physician gave him relief. He has 
had some ankle swelling, especially marked in the 
later afternoon and evening and usually disappearing 
by morning. The only medication he took since his 
last discharge was Darvon and nitroglycerin, neglect- 
ing his digitalis and reserpine. 

His first four admissions, starting at age 50, were 
for hernias and third degree burns of the right leg. 
On the fifth admission, he was treated for acute throm- 
bophlebitis of the right leg. At age 58 he was ad- 
mitted for the sixth time and was discharged with the 
following diagnoses: hypertensive cardiovascular dis- 

ease; arteriosclerotic heart disease with angina and 
aortic stenosis; anterior myocardial infarction, remote; 
pulmonary fibrosis and emphysema; benign prostatic 
hypertrophy; calculus, left kidney; arthritis, cervical 
spine. Chest x-ray at that time showed a heart of 
normal size and no pulmonary infiltration. 

His seventh admission six months later was because 
of left chest, cervical and shoulder pain, and numbness 
of the left arm. The effect of nitroglycerin on his 
chest pain was difficult to evaluate. It was felt that 
he also had a depressive reaction, but he refused 
electroshock therapy. His blood pressure, which was 
230/130, came down to normal levels. 

His eighth admission during the same year was 
again for the same type chest pain radiating into the 
left shoulder and arm. Chest x-ray at that time re- 
vealed calcification of the aortic knob, a tortuous 
thoracic aorta and clear lung fields. 

His present and final admission was approximately 
six months later. 

Physical Examination: Temperature 100.8°, pulse 

90, respiration 20, ht. 71, weight average 185, present 
135, blood pressure 120/65. He was described as a 
poorly nourished, cooperative white male in no acute 
distress. He had slight ptosis of the left eyelid and 
some narrowing of the retinal arterioles. The left 
pupil was slightly smaller than the right. The AP 
diameter of the chest was increased and breath sounds 
were very faint. A few dry rales were heard in the 
left lung base. The heart sounds were distinct with 
regular sinus rhythm and the left border of the heart 
was not percussible. A grade II/VI aortic systolic 


* From the Medical Service Laboratory Service of 
Veterans Administration Hospital, Memphis, Tennes- 
see 38104. 


murmur was heard. Cephalic and chest veins were 
very prominent. All peripheral pulses were palpable. 
There was weakness and poor mobility of the pectoral 
girdle. Neurological exam was normal. Lymph nodes 
were not enlarged. The rectal exam showed throm- 
bosed hemorrhoids and a Grade I prostatic enlarge- 
ment. 

Laboratoi-y Data: Hct. 43%, Hbg. 13.7 gms., WBC 
14,200, neutrophiles 87, lymphocytes 5, monocytes 4, 
eosinophils 4, CSR 31. Urine had a trace of albumin 
with 3-4 WBC and RBC’s and occasional granular and 
hyaline casts. BUN 15 mg.%, CO 2 32.5 mEq/L, 
chlorides 92 mEq/L, sodium 141 mEq/L, potassium 
2.8 mEq/L, STS negative, transaminase 88 units, 
calcium 10.2 mg.%, bilirubin 0.6 mgm.%, spinal 
fluid — colloidal gold normal, chlorides 126 mEq/L, 
sugar 115 mg.%, protein 50 mg.%. 

The admission EKG was abnormal, with ST-T 
changes, prominent P waves and low voltage in the 
limb leads. Subsequent EKGs showed AV block, 2:1 
flutter and findings suggestive of pulmonary embolus 
or infarction. 

X-rays: X-ray on admission revealed the heart to 
be somewhat larger than on previous admission, but 
still within normal limits. The aorta was tortuous, the 
knob calcified. An opacity about the left apex was 
somewhat more prominent than an examination of 
the chest x-ray on a previous admission. 

Hospital Course: He continued to complain of 

chest pain and at times he was confused. On the 
third day he had a marked tachycardia and irregular- 
ities for which he was given potassium. On the fifth 
day he became febrile and had a deep productive 
cough. X-ray of the chest showed some veiling at the 
left base. Rhonchi were present in the posterior aspect 
of both lungs. Sputum showed a few pus cells and 
cultures grew a few colonies of Niesseria species, for 
which he was given antibiotics. Another chest x-ray 
on the eighth day revealed consolidation of the right 
base. A thoracentesis yielded 100 cc. of bloody fluid, 
which contained no organisms. A blood culture was 
obtained. On the 11th day, tonic and clonic seizures 
were observed. His BUN was 97 mgs.%, potassium 
4.3 mEq/L and transaminase 55 units. He expired on 
the 12th hospital day. 

CLINICAL DISCUSSION 

DR. JOHN C. LARKIN, JR.: There are 

not a great many conditions other than malig- 
nancy that will give a picture of constant pain 
for 14 months. I cannot think of any of the 
infectious processes that would cause pain in 
this area, with no disease seen initially radiolog- 
ically, and finally with a small amount of 
disease in this area seen radiologically. Tuber- 
culosis can cause pain but it does not usually do 
so, although it may erode through the chest waU 
and cause a cold abscess and pain. One would 
have seen considerable disease radiologically 
if the symptoms were due to tuberculosis. The 
same picture would be seen in actinomycosis. 


124 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 




which would cause pain also if erosion through 
the chest wall occurred. 

I believe that he had a malignancy beginning 
either in the upper part of the lung, the base 
of the neck or possibly in the cervical or dorsal 
vertebrae, which would give this type of pain 
with radiation down the arm. If it had been 
in the base of the neck, we should have been 
able to feel a mass there. There was no evi- 
dence by x-ray of any bony erosion, and a 
malignancy beginning in the vertebrae would 
have shown some bony change by this time. 

The so-called “superior sulcus tumor” is char- 
acterized by pain in the chest and a radiation 
down the ulnar aspect of the arm. It is very 
frequently associated with a Horner’s syndrome 
due to involvement of the sympathetic chain. 
We are told that this man had slight ptosis and 
miosis. The prominence of the cephalic and 
chest veins could be caused by pressure by the 
tumor on the superior vena cava in the upper 
mediastinum. Finally we see the x-ray abnor- 
mality in the apex which had not been present. 
Frequently one will see bony erosion of ribs 
or vertebrae present as part of the picture. A 
superior sulcus tumor may be due to any neo- 
plasm, but it is usually a bronchogenic carci- 
noma. A metastatic lesion to this area is very 
rare. Occasionally sarcomas occur here. The 
diagnosis can sometimes be confirmed by cy- 
tology. Bronchoscopy may confirm the diagnosis 
only by the aspiration of malignant cells, but 
the tumor cannot be seen or biopsied through 
the bronchoscope. Scalene node biopsy may be 
a means of diagnosis. 

Bronchogenic carcinoma has been associated 
with adrenal cortical hyperfunction. The pic- 
ture has varied from a hypokalemic alkalosis to 
a true picture of Cushing’s syndrome. It is due 
to hyperplasia of the adrenal cortex as a result 
of some ACTH-like material elaborated by the 
tumor. This happens not only in carcinoma of 
the lung, but also with carcinoma of other 
organs, although bronchogenic carcinoma has 
been the most frequent tumor associated with 
it. Undifferentiated bronchogenic carcinoma 
has been the type most often seen. Many of 
these people will have increased amounts of 
steroid in the urine; many of them are abnor- 
mally sensitive to ACTH stimulation; and there 
is no suppression of secretion by dexamethasone. 
This diagnosis in our case is on tenuous grounds, 
and it is based only on the finding of hypo- 
kalemic alkalosis. Although this is not enough 


to make it a diagnosis, it certainly is enough to 
cause one to suspect it. He did have a mild 
lowering of the chlorides also. We are not told 
of any other reasons for his low potassium. He 
did not have diarrhea, vomiting, or gastric drain- 
age, nor did he receive steroids or diuretics. 
All of the above are the more common causes 
of hypokalemia. The diagnosis could be con- 
firmed by studies of the adrenocortical hor- 
mones. 

Later on during his course he had pulmonary 
involvement. On the fifth day he became febrile, 
had a cough, and chest x-ray showed some veil- 
ing. Perhaps he had a pneumonitis or pul- 
monary infarction at that time. Next he 
developed a bloody pleural effusion which 
certainly would go along with pulmonary infarc- 
tion. The chest x-ray was consistent with it, and 
the EKG was suggestive of it. The SCOT 
levels were 88 and 55, neither of which is 
greatly elevated. There have been various vas- 
cular complications with malignancies, and 
migratory thrombophlebitis has been one of the 
early manifestations of malignancy. Most com- 
monly these malignancies have been malig- 
nancies of the abdominal cavity rather than 
the lung, but they have also occurred with 
bronchogenic malignancy. This man did not 
have a migratory thrombophlebitis, but he could 
certainly have had a deep thrombophlebitis. A 
rare occurrence in pulmonary malignancy and 
chronic pulmonary disease is thrombosis of pul- 
monary veins. Most of these patients have had 
active pulmonary tuberculosis. It has been 
thought that they have a pulmonary embolus 
first and then develop thrombosis later. They 
became extremely short of breath and cyanotic; 
some of them have lived for months, although 
most of them die very quickly. Characteristi- 
cally the x-ray shows a radiolucency in the 
lung rather than a density. I mention this only 
as a distant possibility in this patient. 

There are several explanations for the convul- 
sion. We know that bronchogenic carcinoma 
metastasizes to the brain vary frequently and 
may cause convulsions. Another possibility is 
that of multiple emboli to the brain from non- 
bacterial verrucous endocarditis which occurs 
in malignancy. One of the vascular complica- 
tions in malignancy and various debilitating 
diseases is non-bacterial verrucous endocarditis 
in which these vegetations occur on the valves, 
most commonly on the mitral and less com- 
monly on the aortic valves. Their chief mani- 


FEBRUARY, 1973 


125 


festation is embolization without fever or other 
findings directed to the heart. One of the most 
frequent forms of embolization is cerebral 
embolization. Paradoxical embolism is a very 
rare possibility. 

One thing I cannot explain is the rise in BUN 
from 16 to 97 mgs.%. Vomiting or diarrhea 
may be possible causes. The potassium did 
not rise during this time. Embolization to the 
kidney could cause a rise in BUN, but renal 
infarction is usually accompanied by rather 
severe pain and usually by some hematuria, 
neither of which we are told that this patient 
had. I do not think that his previously known 
cardiac disease played a part in the final illness 
other than possibly contributing to pulmonary 
embolization. 

My diagnoses are (1) superior sulcus tumor, 
bronchogenic carcinoma type; (2) probable 
adrenal cortical hyperplasia; (3) pulmonary in- 
farction; (4) probable cerebral metastases from 
carcinoma, although I cannot be sure that he 
did not have emboli from non-bacterial endo- 
carditis; (5) arteriolar nephrosclerosis; (6) 
renal calculus and possible pyelonephritis; (7) 
calcific aortic stenosis; (8) arteriosclerotic heart 
disease with old myocardial infarction. 

ANATOMIC FINDINGS 

DR. J. M. EMANUEL: At the time of 

autopsy there was a small amount of straw- 
colored fluid in the right pleural space. The 
right lung weighed 800 grams and approximately 
half of the lower lobe was infarcted; and many 
partially organized thrombi were noted in the 
radicles of the pulmonary artery. 

The left lung was removed with difficulty and 
a mass was noted in the apical region of the 



Fig. 1 Apex of lung 



Fig. 2 Photomicrograph, X60, showing adenocarci- 
noma 


left pulmonary cavity. This mass was removed 
with great difficulty; it was torn loose from the 
apex of the lung as the lung was removed. 
Figure 1 is simply serial sectioning through the 
mass showing a small amount of lung tissue, 
anthracotic pigment, and the tumor, which was 
1x5 cm. in gross dimensions. Figure 2 is a 
microscopic section of this tumor showing the 
cuboidal to columnar epithelial cells that make 
up these gland-like structures which contain a 
small amount of slightly basophilic staining, 
mucoid-like material. Also, it shows a dense 
fibrous stroma. It is a moderately well- 
differentiated adenocarcinoma with many mi- 
toses. Malignant cells were present in the 
thoracentesis fluid. 

The heart and pericardium also were in- 
volved. The pericardial sac contained approxi- 
mately 200 cc. of unclotted blood. The surface 
of the heart was covered with fibrinous material, 
and the ascending aorta and pulmonary artery 
were involved by masses of dense tumor tissue. 
The same type of tumor invaded the epicardial 
fat on the heart. Figure 3 is a view of the 
heart showing fibrinous pericarditis, a nonbac- 
terial thrombotic endocarditis of the aortic valve, 
and the myocardium thinned out with a large 
mural thrombus at the apex. There was embol- 
ization from either this thrombus or the verrucae 
of the endocarditis because, as you will see 
later on, he did have infarction of other organs. 
The apical myocardium showed infarction and 
inflammation. The aortic valve showed ver- 
rucous masses composed of fibrin with some 
organization. 

A section through a kidney showed a partially 
organized thrombus lying in a large artery. 


126 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



Fig. 3 Heart with verrucous endocarditis of aortic 
valve, fibrinous pericarditis and area of apical 
thinning with mural thrombus. 


Both kidneys had areas of infarction, and this 
probably is one reason that his BUN was 
elevated. 

There were metastases to the mediastinal 
lymph nodes showing the same type adeno- 
carcinoma and some of the nodes were described 
as being 5 cm. in diameter. In reviewing the 
chart I noted that the patient developed a 
hoarseness in December 1964, which was ap- 
proximately two months before he died, and 
this indicates involvement of the recurrent 
laryngeal nerve. The tumor did involve peri- 
tracheal, right hilar and left hilar nodes. 

He also had a metastasis to the hypothalamus 
on the left, and I might note that some of the 
previous earlier convulsions noted were de- 
scribed as jerking in the right shoulder and jaw, 
and then generalized tonic and clonic seizures 
were described just before he died. In the left 
occipital region he had a thrombus in a vessel 
with an area of infarction. 

In addition, the adrenals were described as 
being enlarged and showing diffuse areas of 
golden yellow cortical hyperplasia, confirmed 
by sections. There was also an adenocarcinoma 
of the prostate, which showed perineural lym- 
phatic invasion, but the two tumors are distinctly 
different and are of different origin. This 
patient did have a superior sulcus tumor of 
the bronchogenic, adenocarcinoma type. 

FINAL ANATOMICAL DIAGNOSES 

1. Superior sulcus bronchogenic adenocarci- 
noma, left, with metastases to regional lymph 
node, hypothalamus, epicardial fat, and as- 
cending aorta. 


2. Generalized arteriosclerosis. 

3. Non-bacterial verrucous endocarditis, aortic 
valve. 

4. Multiple infarcts, kidneys, heart, and left 
occipital lobe. 

5. Multiple pulmonary emboh with infarctions, 
right lung. 

6. Adenocarcinoma of prostate. 

DR. HUGHES: Are squamous cell tumors 
the most common? 

DR. EMANUEL: My impression is that the 
squamous tumor is the most common. How- 
ever, I did see an article^ recently trying to 
correlate the superior sulcus tumors with apical 
scars and in most of their cases the patients 
had adenocarcinomas. 

DR. YOUNG: Bronchiolar carcinoma has 

also been reported. This is a particularly good 
teaching case, I think, because the patient 
received no irradiation to the tumor. It illus- 
trates very well, too, why one frequently does 
not get positive findings from bronchoscopy. 
The lesions are in the periphery of the lung 
and invade the adjacent structures before they 
involve bronchi. This tumor invaded the lung 
tissue only to a very limited degree. In some of 
these peripherally placed lesions one can have 
calcified areas that are actually surrounded by 
the growth of tumor. The finding by x-ray of 
calcification in them would not rule out a 
carcinoma. While other tumors can involve 
this area of the brachial plexius and give the 
so-called superior sulcus syndrome as Dr. 
Larkin pointed out, bronchogenic carcinoma is 
certainly by far the most common tumor to do 
so. This particular tumor today I think be- 
haved so everybody could be right in his diag- 
nosis from the pericarditis to the myocardial 
infarction by marantic thrombi. Dr. Larkin, 
how would you go about diagnosing a superior 
sulcus tumor if you suspected one on the basis 
of a few physical findings and the history of pain 
such as this patient had. Would you use a 
needle biopsy perhaps? 

DR. LARKIN: Well, certainly cytology and 
probably bronchoscopy would be indicated. I 
do not believe that I would do a needle biopsy. 

BIBLIOGRAPHY 

1. Solovay, Julius, MD, Solovay, HU, MD, FCCP: 
Apical Pulmonary Tumors — Relation to Apical Scar- 
ring, Dis of the Chest 48:20, 1965. 


FEBRUARY, 1973 


127 


n aM 'l 

^ of the month j 

HISTORY 

This 50 year old gentleman began to experience 
angina pectoris approximately two months prior to 
admission to St. Thomas Hospital. His symptoms 
were originally related to exertion, but more recently 
occurred also at rest. Because of the progressive nature 
of his symptoms he was admitted for coronary 
arteriography. Illustrated are his admission ECG 
(Fig. 1), ECG taken during angina pectoris while at 
bed rest the morning before coronary arteriography 
(Fig. 2), ECG one hour later following resolution of 
chest pain (Fig. 3) and a single frame view (from 
the cineangiogram) of the left coronary artery in left 
anterior oblique projection (Fig. 4) showing severe 
occlusion of the proximal anterior descending coronary 
artery. 


DISCUSSION 

Transient marked ST segment elevation oc- 
ciiring during resting angina pectoris was origi- 
nally described by Prinzmetal/ a syndrome now 
commonly referred to as “variant angina.” It 
was Prinzmetal’s impression that this phenom- 
enon usually indicates significant isolated ob- 
struction of the major coronary artery supply- 
ing the ischemic myocardium associated with 
the ST segment elevation. Patients demonstrat- 
ing this phenomenon are felt to have a high 
incidence of subsequent myocardial infarction. 
Subsequent reports in the literature suggest that 
this syndrome is more heterogenous than origi- 
nally assumed and variations on the original 
description are relatively frequent. Although 
the patients originally described by Prinzmetal 
were found to have no symptoms or ECG 
changes during exercise, other patients have been 


Tm 


tl Kt 



Fig. 1 





Fig. 2 



Fig. 3 



Fig. 4 


From: St. Thomas Hospital, Department of Cardi- 
ology, Nashville, Tennessee, 


128 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


subsequently noted to have angina and transient 
ST elevation with exercise. Some patients with 
this phenomenon have been asymptomatic with 
normal ECG’s for many years following these 
ST changes. More recently reports have ap- 
peared of normal coronary arteriograms in 
patients with otherwise typical variant angina. 

Why the ST segments become elevated rather 
than depressed in variant angina is unknown. 
The etiologic role of possible associated coro- 
nary arterial spasm, transient platelet aggraga- 
tion in small coronary vessels, etc., remains a 
moot question. In spite of the inevitable excep- 
tions to previously formed generalizations about 
the syndrome, it seems reasonable to assume 
that patients exhibiting this phenomenon are at 
increased risk of myocardial infarction and 
should be so treated until proved otherwise.^ 


This patient underwent a saphenous vein bypass 
graft to his anterior descending artery with 
gratifying clinical results and stabilization of 
his ECG. 

Final ECG diagnosis: Transient ST segment 
elevation of the “variant” or “Prinzmetal” 
variety. 

Final anatomic diagnosis: Isolated segmental 
obstruction, anterior descending coronary artery. 


Harry L. Page, Jr., M.D. and W. Barton Campbell, 
M.D., Co-directors. 

1. Prinzmetal, M; Kennamer, R; Wada, T; Bor, N; 
Angina Pectoris I. A Variant Form of Angina Pectoris, 
Amer J Med, 27:375, 1959. 

2. Silverman, ME; Flamm, MD, Jr; Angina Pectoris 
Anatomic Findings and Prognostic Implications. Ann 
Int Med, 75: 339, 1971. 


Survey of Licensed Physicians by County in the State of Tennessee. This study reveals 
the number of licensed physicians compared with TMA membership in each County. 


*Licensed 

T.M.A. 

*Licensed 

T.M.A. 

*Licensed 

T.M.A. 

*Licensed 

T.M.A. 

County Physicians Members County Physicians Members County Physicians Members County Physicians Members 

ANDERSON 

78 

71 

FENTRESS 

4 

3 

LAUDERDALE 

8 

6 

ROANE 20 

15 

BEDFORD 

15 

12 

FRANKLIN 

12 

10 

LAWRENCE 

15 

13 

ROBERTSON 11 

10 

BENTON 

5 

5 

GIBSON 

25 

21 

LEWIS 

4 

3 

RUTHERFORD 59 

43 

BLEDSOE 

2 

2 

GILES 

7 

7 

LINCOLN 

14 

12 

SCOTT 7 

7 

BLOUNT 

58 

54 

GRAINGER 

3 

2 

LOUDON 

9 

8 

SEQUATCHIE 2 

2 

BRADLEY 

36 

34 

GREENE 

30 

27 

McMINN 

25 

18 

SEVIER 17 

14 

CAMPBELL 

13 

10 

GRUNDY 

2 

1 

Mcnairy 

7 

4 

SHELBY 1479 

946 

CANNON 

5 

5 

HAMBLEN 

32 

25 

MACON 

3 

2 

SMITH 7 

7 

CARROLL 

8 

6 

HAMILTON 

400 

344 

MADISON 

82 

74 

STEWART 2 

1 

CARTER 

19 

16 

HANCOCK 

1 

1 

MARION 

12 

11 

SULLIVAN 180 

143 

CHEATHAM 

3 

2 

HARDEMAN 

14 

9 

MARSHALL 

13 

11 

SUMNER 25 

21 

CHESTER 

4 

4 

HARDIN 

12 

9 

MAURY 

38 

34 

TIPTON 14 

9 

CLAIBORNE 

8 

5 

HAWKINS 

9 

7 

MEIGS 

2 

2 

TROUSDALE 3 

2 

CLAY 

4 

3 

HAYWOOD 

9 

6 

MONROE 

11 

10 

UNICOI 5 

4 

COCKE 

8 

7 

HENDERSON 7 

7 

MONTGOMERY 42 

41 

UNION 1 

1 

COFFEE 

18 

15 

HENRY 

24 

21 

MOORE 

1 

1 

VAN BUREN 1 

1 

CROCKETT 

4 

4 

HICKMAN 

3 

3 

MORGAN 

1 

0 

WARREN 12 

12 

CUMBERLAND 

19 

18 

HOUSTON 

4 

3 

OBION 

27 

22 

WASHINGTON 101 

87 

DAVIDSON 971 

673 

HUMPHREYS 7 

5 

OVERTON 

9 

5 

WAYNE 3 

3 

DECATUR 

2 

2 

JACKSON 

5 

4 

PERRY 

3 

2 

WEAKLEY 15 

15 

DEKALB 

6 

3 

JEFFERSON 

12 

12 

PICKETT 

2 

2 

WHITE 8 

6 

DICKSON 

12 

8 

JOHNSON 

4 

3 

POLK 

6 

5 

WILLIAMSON 20 

16 

DYER 

29 

24 

KNOX 

467 

380 

PUTNAM 

27 

23 

WILSON 14 

14 

FAYETTE 

8 

8 

LAKE 

3 

3 

RHEA 

7 

3 

TOTAL 4805 

3595 

*Licensed physicians 

include a number 

of physicians 

who have retired or are living out of State. They 

are in- 

eluded in the 

totals 

because many are 

veteran 

members of the Association. 





FEBRUARY, 1973 


129 



THE COOPER QUIZ* 

(answers to be found on pages 170, 171, 172, 173, 175) 

True or false except as indicated. 


1. Marihuana smoking causes an increase in pulse rate and an increase in limb blood flow. 
This is the result of a) vagal activity (b) beta-adrenergic mechanisms 

2. Because of the cardiovascular effects . of marihuana smoking, when these people are in- 
volved in traffic accidents, the use of premedication with atropine and the use of local 
anesthetics containing epinephrine may be dangerous. 

3. Persons with sickle-cell anemia may develop hemolytic crisis if their G-6-PD level falls 
too low (as a result of infection or drugs). 

4. Hyperactive children treated with stimulants definitely have a suppression of weight gain. 
It is entirely possible that long-term administration of stimulant drugs may cause increased 
growth (height). 

5. Immunosuppressive drugs are used in the treatment of immunologic disorders with the hope 
that they will inhibit the production of pathogenic antibodies or suppress the inflammatory 
responses caused by antigen-antibody reactions. 

6. Which kinds of infections have more of the so-called “natural antibodies”? 

(a) streptococcal and pneumococcal infections 

(b) enteric gram-negative bacilli infections 

7. When using cytotoxic drugs, leukopenia must be induced before there is any beneficial 
effect. 

8. Termination of pregnancy is considered relatively a safe procedure. Bleeding, uterine per- 
foration, infection and thromboembolism are well known complications. No complications 
have been reported after the use of intra-amniotic injection of hypertonic saline solution. 

9. The frequency of death, recurrent embolism and bleeding have been (a) more (b) less 
when heparin is given intravenously. 

10. It is (certain) (uncertain) that monitoring the dose of heparin offers any advantage over 
the standard dose regimen. 

11. A recent Canadian study suggest that the recurrence of venous thromboembolism is rare 
during heparin administration if the dose is adjusted to prolong the activated partial throm- 
boplasin time to greater than 1% times control levels. 

12. The reason atropine is used in the treatment of patients with heart disease is to prevent a 
slow rate reducing the cardiac output. 

13. Chronic analgesic ingestion may induce thrombocytopenia. This is due to (a) the drug 
itself (b) a metabolite of the drug. 

14. Any increase in the maintenance dose of salicylate will result in more than a proportional 
rise in the plateau level of salicylate in the body. 


* We are indebted to William T. Snagg, M.D., Quiz.” Published monthly by the Dept, of Medical 

Director of Medical Education, The Cooper Hospital, Education, The Cooper Hospital, Camden, N.J. 08103. 

for permission to reprint portions of “The Cooper 


130 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


15. Fingerprints in women may be used to suspect spontaneous abortions. 

16. Both infections and viral hepatitis can be transmitted by either the oral or parenteral route. 

17. Serum concentrations of IgM are higher (early in the disease) in viral hepatitis than in 
serum hepatitis. However, there is too much overlap of values to make this a reliable 
criterion. 

18. Thymol turbidity levels are (during the acute phase) higher in infectious hepatitis than in 
serum hepatitis. The difference makes this a satisfactory criterion for differential diagnosis. 

19. Stamonium by mouth is relatively non-toxic, but inhaled (as smoke) it is toxic. 

20. Arteriosclerosis producing stroke seems more related to the level of hypertension than to 
cholesterol blood level. 

21. An English drug albuterol (salbutanol) has many properties of isoproterenol; recently its 
effect as an aerosol on asthma has been compared with isoproterenol. Which had the longer 
bronchial dilating effect? (a) isoproterenol (b) albuterol 

22. Many laboratories when measuring VMA (test for pheochromocytoma) require rigid dietary 
restriction before and during urine collections. It has recently been proven that diet (does) 
(does not) influence VMA levels. 

23. Long-term hemodialysis in small children can be done successfully. Failure to grow during 
treatment occurs in most of these children. 

24. Brain scanning in children yields its greatest rewards in cases of generalized seizures and 
mental or behavioral abnormalities. 

25. Is it possible to diagnose chronic active hepatitis without a liver biopsy? 

26. There are no drugs that will increase athletic performance. 

27. One of the physiologic effects that makes marathon running possible is the ability not to 
accumulate blood lactate. 

28. In an Albany study of Hodgkin’s disease that covered two decades, there is found a pattern 
that was similar to that of an infectious disease. 

29. The Albany study of Hodgkin’s disease suggests that a carrier (was) (was not) involved. 

30. In iron deficiency anemia, cobalt absorption is (increased) (decreased) 

31. In using cobalt as a test for iron deficiency, the urinary excretion of cobalt is much less 
in iron deficient anemia than in anemia of other causes. 

32. The use of radioactive cobalt in testing for iron deficiency should be restricted because of 
cobalt toxicity and radiation exposure. 

33. Farmer’s lung is in reality an attack of asthma resulting from repeated exposures to moldy 
hay. 

34. After months or more of exposure the patient with farmer’s lung may present with a picture 
indistinguishable from that of diffuse interstitial fibrosis. 

35. Hilar lymphadenopathy is a roentgenologic feature of farmer’s lung. 


FEBRUARY, 1973 


131 



VITAMIN B12— REVISITED:* 

THE SCHILLING TEST 

Because knowledge of the biochemistry and 
physiology of Vitamin B12 has recently ex- 
panded, because improved methods of testing 
important parameters of Vitamin B12 meta- 
bolism have been developed, and because some 
of the tests of Vitamin B12 metabolism which 
were promoted at an earlier time are withering 
from disuse atrophy, it seems reasonable to 
revisit this interesting clinical area2’^ 

Vitamin B12 is essential for life, is manu- 
factured only by certain microorganisms, and 
is physiologically active in extremely small 
quantities. It combines with adenosine to form 
a group of coenzymes which are important in 
methylation, DNA synthesis, Ribosome protein 
synthesis, and lipid metabolism. The methyla- 
tion reactions are essential for the utilization of 
folic acid and the transfer of folic acid into 
cells. Hence, in Vitamin B12 deficiency, folic 
acid levels are high in the serum and low in the 
cells. ^ The DNA synthesis is critical in the 
proper maturation of hemopoietic cells. 

Vitamin B12 can be absorbed only if there is 
enough gastric acidity to release it from ingested 
protein, if the stomach has manufactured enough 
intrinsic factor with which the Vitamin B12 can 
form a complex, if the complex can attach to the 
ileum, and if the active transport system in the 
ileum functions normally to transfer the Vitamin 
B12 to receptor proteins in the blood stream. 
Approximately eight hours after ingestion, maxi- 
mal concentrations of the Vitamin will be seen 
in the serum. 

When there is atrophy of gastric mucosa 
from any cause (e.g.: autoimmune reactions, 
surgery, radiation, chemical damage) not enough 
intrinsic factor is produced and reduced absorp- 
tion of B12 results. If antibodies to intrinsic 
factor or to the intrinsic factor — B12 complex 
are present, absorption by the ileum will be 
prevented and reduced blood levels will ensue. 
If there is primary disease of the ileum, reduced 
absorption of B12 results. If fish tapeworm or 
bacteria are present in blind loops or in diver- 

" From the Department of Nuclear Medicine, Park- 
view Hospital, Nashville, Tenn. 

132 


ticula, they may utilize most of the vitamin and 
reduced absorption of Vitamin B12 results. 
Finally, poorly understood reduced absorption 
of Vitamin B12 can be seen in gluten enter- 
opathy, exudative enteropathy associated with 
skin diseases, severe pancreatic disease, severe 
malabsorption syndrome with diarrhea, and as a 
familial disorder in some children. In all of 
these conditions, the serum level of Vitamin B12, 
both bound and unbound, will be reduced. 

Once in the blood stream. Vitamin B12 will 
normally combine with transcobalamin II (a 
beta globulin) and will quickly leave the blood 
and be carried to the cells. Almost 50% will be 
taken up by the liver. Significant amounts will 
be taken up by the hematopoietic system and 
by endocrine glands. The vitamin will be re- 
tained by tissues for a very long period of time. 
Excretion is principally via bile. Only when the 
normal protein binding sites are saturated, will 
any B12 be excreted by the kidney. Diseased 
kidneys may, of course, reduce the excretion of 
excess B12. Some Vitamin B12 will combine 
with transcobalamin I, an alpha globulin, prob- 
ably as it leaves body cells and circulates again 
in serum. In chronic myelogenous leukemia 
large quantities of Vitamin B12 are seen in the 
blood and almost all of it is attached to trans- 
cobalamin I. In hepatoma, the Vitamin B12 
binds to a specific abnormal gamma globulin, 
while in polycythemia and leukocytosis an ab- 
normal protein (possibly transcobalamin III, a 
beta globulin) binds most of the B12. In 
myelologenous leukemia, polycythemia, leukocy- 
tosis, and hepatoma, the serum B12 levels are 
elevated. 

In the nuclear medicine laboratory, the class- 
ical Schilling test, developed in the early 1950’s, 
led to significant improvement in the evaluation 
of patients suspected of having pernicious 
anemia or subacute combined disease of the 
nervous system, and still is the mainstay of 
diagnosis. Since those days ^'^cobalt has replaced 
^'"cobalt as a label for Vitamin B12, because it 
delivers less than 1/30 of the dose of radiation 
to a patient and the energy of its gamma ray 
is more easily utilized. 

Tests of liver uptake of Vitamin B12 have 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


not stood the test of time principally because 
variations of liver size, shape, and function made 
standardization of the tests impossible. Further- 
more, ®®cobalt in large quantities had to be 
utilized, and the test usually took seven to ten 
days. Similarly, plasma levels of absorbed Vita- 
min B12 have not gained wide acceptance in 
the literature, because low counting rates led to 
long counting time and poor statistics, and it 
was often inconvenient to draw blood eight 
hours after ingestion of the B12. Tests of 
Glomerular filtration with labelled Vitamin B12 
have also fallen by the wayside, principally be- 
cause large doses of labelled B12 were needed 
(relatively expensive) and better radiopharma- 
ceuticals have been developed. Finally, whole 
body counters, which are relatively expensive 
installations, are not heavily utilized for clinical 
B12 absorption studies even in institutions 
where this facility is available because it takes 
seven to ten days to complete the test. 

The classical urinary Schilling test, when used 
in conjunction with intrinsic factor or antibiotics 
as needed, provides information about primary 
pernicious anemia, blind loop syndrome, and 
primary disease of the ileum. If the serum 
Vitamin B12 level using a radiosorbent tech- 
nique'* receives the rapid acceptance that it 
appears to deserve, and if DEAF column separa- 


tion of various transcobalamins become more 
widely available, then Vitamin B12 studies will 
take on added significance in the evaluation of 
patients with myeloproliferative diseases, with 
hepatomas, and with polycythemia. Finally, 
“"cobalt Vitamin B12 has now been successfully 
utilized at the operating table for localization of 
relatively small parathyroid adenomas.® This, 
of course, necessitates special (though not ex- 
cessively expensive) counting equipment and 
large (relatively expensive) doses of “^cobalt 
labelled B12. 

REFERENCES 

1. Blahd, WH: Nuclear Medicine, 2nd edition. 

2. Cooper, RM: Vitamin B12 Proteins: The Diag- 
nostic Significance. Continuing Education Lectures, 
1972, Southeastern Chapter Society of Nuclear Medi- 
cine. 

3. Herbert, V, et al: B12 dependence of cell uptake 

of serum folate: An Exploration for High Serum 

Folate and Cell Folate Depletion in B12 Deficiency. 
Clinical Research. 20:489, 1972. 

4. Wilde, L and Kellander, A: Radiosorbent Technic 
for Assay of Serum Vitamin B12. Scandinav J Clin 
and Lab Invest. 27:151, 1971. 

5. Workman, JB, and Connor, TB: Operative 

Localization of Parathyroid Adenomata: J Nuc Med. 
5:372, 1964. 

Robert L. Bell, M.D., Director 

230-25th Ave., No. 

Nashville, Tenn. 37203 


The Return of the Scabies Mite 

After an absence of almost two decades the 
itch mite (Sarcoptes scabei) has returned to 
reside with a sizable portion of the world’s 
population. Children and young adults appear 
to be especially susceptible, particularly when 
living under conditions of crowding and poor 
personal hygiene. The epidemic recurrence of 
scabies every 15 to 20 years is thought to have 
an immunologic basis. 

Diagnosis is made by finding the body or 
parts of the body of the tiny (0.35 mm) mite, 
usually at the end of a burrow. The lesions, 
some of which may be vesicular, are charac- 
teristically found in the interdigital spaces of 
the fingers, the palms, the wrist flexures, the 


inner and posterior side of the elbows, the 
anterior axillary folds, belt line, buttocks, and 
the margins of the soles of the feet. 

The diagnosis can be easily missed if the 
lesions are sparse, as they frequently are, or if 
their appearance is altered by topical steroids, 
certain irritating medications or by scratching 
and rubbing. 

Robert M. Adams, M.D. 

REFERENCES 

Duffy, DM: Ectoparasitic infestations. Cutis 7:161- 
168, Feb. 1971. 

Orkin, M: Resurgence of scabies. JAMA 217:593- 
597, Aug. 28, 1971. 

— Reprinted from California Medicine, Aug. 1972. 


FEBRUARY, 1973 


133 




ffOfll 


Establishment of State Center 
For Health Statistics Recommended 

The Biostatistics and Epidemiology Depart- 
ments of the Tennessee Mid-South Regional 
Medical Program felt the need for standardized 
health data in the state of Tennessee. Dr. Paul 
E. Teachan, Director of the Tennessee Mid- 
South Regional Medical Program, contacted Dr. 
Eugene Fowinkle, Chairman of the Tennessee 
Department of Public Health, to determine if a 
study could be made to see if a state center 
for health statistics was needed in Tennessee. 
A meeting of interested health professionals was 
set up, and it was decided that a task force 
should be formed to study the problems of 
health data fragmentation. 

The task force was set up by the Tennessee 
Health Planning Council, a division of the 
Tennessee State Department of Public Health. 
Members included representatives of federal, 
state and local heatlh agencies, insurance com- 
pany representatives and others interested in the 
need for standardized health data in the state. 
It has recommended that a state center for 
health statistics be established here in Tennes- 
see. The center would gather all data pertaining 
to health, which would include demographic 
data, mortality data, health cost data, and 
statistics relating to needs in certain areas of 
the state. 

The Health Planning Council has already 
received an H.E.W. grant to conduct surveys 
and gather statistics in three areas: availability 
of health manpower, physical health facilities in 
Tennessee, and health needs of the health con- 
sumer in Tennessee. This information will pro- 
vide an important beginning to the functions of 
the state center for health statistics when it is 
established. (See “From the Dept, of Public 
Health,” p. 157, this issue.) The task force 
also recommended that the center should in- 
clude in its work program a number of functions 


not presently undertaken by existing agencies, 
but should also incorporate some current activ- 
ities including data collection, standardization, 
processing, analysis, evaluation, dissemination, 
special studies, program assistance, and informa- 
tion referral. 

A subcommittee on functions of a data refer- 
ral center recommended the state center for 
health statistics be headed by a director, to be 
responsible for the overall operation of the 
center and to oversee the activities of four assis- 
tant directors in charge of vital records, data 
processing, statistics and information and refer- 
rals, respectively. They also recommended that 
an advisory committee be set up to assist the 
center in the periodic review of the usefulness 
of the data and to provide feedback to the 
director on how outsiders view the operation of 
the center. Members of the advisory commit- 
tee, they said, should be knowledgeable users 
of health data. 

A second subcommittee appointed to estab- 
lish the need for such a center pointed out that 
although there are health statistics available in 
Tennessee, some of them are outdated. There 
is also some duplication of surveys, and there 
is fragmentation and poor coordination of health 
statistics. Although some of the surveys are 
good, some people do not know how to go 
about finding health data information. A 
bibliography of statistical data on health plan- 
ning in Tennessee prepared by the Office of 
Comprehensive Health Planning lists 543 data 
files from approximately 1,200 different sources. 

The task force recommended the center be 
located administratively in the Tennessee De- 
partment of Public Health and be financially 
supported from funds already being used for 
data services, from additional allocations from 
the state legislature, and from funds possibly 
available through grant applications to the U.S. 
Department of Health, Education and Welfare. 


134 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


from the 
CMCcutive 
dkcclof 

J. E. BAUENTINE 


f mCDICm DKi£5T 

NEiVS OF INTEREST TO DOCTORS IN TENNESSEE 


PSRO's . . AMA will "provide a dominant role of leadership in the imple- 
mentation of the PSRO program to assure that the best interest of the 
public and the profession are preserved," as decreed by the AMA House 
of Delegates in December ... An Advisory Committee on Professional 
Standards Review will be created. It will include members of AMA 
Board and the Council on Medical Service. Other appropriate organiza- 
tions will be invited to participate. Among responsibilities of the 
Committee will be; (1) to provide input from the medical profession in 
the development of rules and regulations which will govern the PSRO 
program; (2) to assist state medical associations, separately, or in 
concert with county societies, in developing PSRO's and to recommend 
structures and operating mechanisms for such organizations ; (3) to aid 
in defining appropriate geographic boundaries for PSRO's, especially 
where more than one state may be involved. Such a committee will also 
develop and distribute information about Public Law 92-603 to state 
associations; monitor the effect of PSRO on medical care, and report 
to each future House session, and instruct the House and state associa- 
tions on procedures to follow "whenever rules and regulations inter- 
preting the law and published in the Federal Register seems to be 
contrary to the spirit of the law as written." 

❖ * * 


WILL PSRO's "STANDARDIZE" MEDICINE? . . . Since PSRO's is the Federal 
Government vehicle for continual scrutiny of the services covered by 
Medicare and Medicaid, "standards" is the key word. Standardizing 
medical care is one way the Federal Government is going to try and meet 
what it sees as its obligations to hold down cost and assure quality. 

The greatest concern to physicians across the country is the possibility 
that these standards might force them into an undesirable uniformity of 
practice . . . PSRO's will assume responsibility for comprehensive 
review of services covered by Medicare and Medicaid programs. Until 
January 1, 1976 only qualified physician-sponsored organizations can 
be so designated in the respective districts of each state, as defined 
by the Secretary of HEW . . . Priority will be given to qualified 
physician organizations first, but if they do not qualify or assume the 
responsibility, HEW may designate another organization as the PSRO for 
the area. 


NO HEALTH CRISIS . . . The United States is not suffering the effects of 
a "health crisis," but, has in fact, made "enormous progress in improv- 
ing the health of the American people since 1950," according to Harry 
Schwartz, author of a new book entitled "The Case for American 


LEGISLATIVE COMMITTEE SPONSORS CONFERENCE ... The TMA Legislative 
Committee sponsored a one-day Legislative Conference in Nashville 
February 4, 1973. The meeting attracted more than 100 contact doctors, 
Auxiliarians and interested physicians from across the state. Governor 
Dunn, Lieutenant Governor Wilder and Speaker of the House Ned 
McWherter appeared on the program. In addition. Commissioner of Public 
Health, Dr. Eugene Fowinkle, and Commissioner of Mental Health, Dr. 
Richard Treadway, appeared on the program. Mr. James W. Foristel, 
Assistant Director of Congressional Relations for AMA in Washington, 
spoke on National Health Legislation. Congressman John Duncan of 
Tennessee's 2nd Congressional District and a member of the House Ways 
and Means Committee was the luncheon speaker. Dr. Rex Kenyon of 
Oklahoma City, a member of the American Medical Political Action Com- 
mittee Board of Directors, was a participant. Dr. Robert L. Bomar of 
Nashville is chairman of the TMA Legislative Committee. 


MEDICARE AMENDMENTS OF IMPORTANCE TO PHYSICIANS ... The Equitable 
Life Assurance Society, Medicare fiscal intermediary in Tennessee, calls 
attention to a recent change in the Medicare Law that increases the 
Part B Medicare deductible from $50 to $60. The $10 increase became 
effective January 1, 1973. All Medicare beneficiaries were notified 
of the increase when they received their monthly benefit checks from 
the Social Security Administration. Because many beneficiaries may 
direct questions regarding the deductible to their physicians, this is 
important information for office workers and staff. 

Equitable reminds that it is most important to note that covered 
expenses incurred during the last three months of 1972 that are used to 
satisfy the deductible for 1972 may be carried over to satisfy the 
deductible for 1973. Only those amounts used to satisfy the deductible 
can be carried over. Patients may be confused by this carry-over 
provision now that the amount of the deductible has increased $10.00. 
There may be situations where $50.00 in covered expenses incurred during 
the last three months of 1972 were used to satisfy the 1972 deductible 
and were applied toward the 1973 deductible. In 1973, an additional 
$10.00 would still have to be applied toward the deductible for that 
year. 

For your convenience we are including an illustration of four 
possible situations showing the effect of the carry-over provision. 


CHARGES INCURRED CARRY-OVER 

1972 DEDUCTIBLE DEDUCTIBLE 

JAN.-SEPT. OCT.-DEC. PROVISION 1973 


$150.00 

$100.00 

None 

$ 60.00 

None 

$150.00 

$ 50.00 

$ 10.00 

$ 25.00 

$ 15.00 

$ 15.00 

$ 45.00 

$ 30.00 

$125.00 

$ 20.00 

$ 40.00 


Any inquiries regarding the Part B Medicare Program should be 
directed to the Equitable Life Assurance Society's office, located in 
Nashville. The mailing address is P. 0. Box 1465, Nashville, 37202. 
Telephones 615/244-5600. 



Wm. T. Satterfield 


pfc/idcniV 

pci^ 


The Annual Meeting 

The Annual Meeting of TMA is an important event. At this event, in 
addition to scientific and social benefits, the ruling body, the House of 
Delegates, makes policies and regulations that govern the Association. 
Perhaps we should take a look at what goes into our Annual Meeting. 

Planning begins four to five years in advance. Meeting places, 
lodgings, exhibit locations and banquet facihties must be secured. 
Speakers are usually committed months in advance. Many trips are 
made to the meeting site during the year before the dates arrive. 

Three or four days preliminary to the gathering, at least one rented 
truck and several staff members’ private automobiles are loaded at the 
headquarters offices and typewriters, copying machines, and reams of 
printed paper are transported. There is a master plan — a step-by-step 
detailed plan — that must not be deviated from. The plan has options of 
change, in cases of emergency, and every item, down to pencils labeled 
“Tennessee Medical Association,” are accounted for. 


Who does all this so efficiently? Our Executive Staff consists of “pros.” 
Many years of experience result in one of the most efficiently run 
Annual Meetings in the country. The Staff has help from dedicated 
committee members on several standing committees. Among these are 
Scientific Affairs, which has an important function in scientific program 
planning. Cooperative specialty groups dovetail their programs. 
Speakers are procured by the Committees on Religion, Socio-economics, 
IMPACT, by the Trustees, by the Staff, and by individual members. 

The Annual Meeting is the one most important event of TMA’s year. 
It brings members together where they may make rules, elect officers, 
obtain scientific credits, hear important speakers on important subjects, 
attend their specialty conferences, and just get better acquainted with 
their fellow members. 


The 1973 Annual Meeting program is complete. The scientific 
speakers, general and specialty, are well-known and respected. The 
socio-economic speakers are outstanding and nationally known. Exhibits 
are superior. TMA members offering resolutions, committee and officer 
reports, and testimony at Reference Committees make member 
participation at the Annual Meeting widespread. All members of TMA 
have the opportunity of expressing their views on any subject. 

TMA has been fortunate in having had weU organized, efficiently 
executed Annual Meetings. They are well worth attending! 


Sincerely, 

President 



joumcil 

OF THE 

TENNESSEE MEDICAL ASSOCIATION 
PUBLISHED MONTHLY 

DEVOTED TO THE INTERESTS OF THE MEDICAL 
PROFESSION OF TENNESSEE 

OFFICE OF PUBLICATION, 112 LOUISE AVENUE, 
NASHVILLE, TENN. 37203 

JOHN B. THOMISON, M.D., EDITOR 

ADDISON B. SCOVILLE, JR., M.D., ASSOCIATE EDITOR 


Acceptance for mailing at special rate of postage provided 
for in Section 1103, Act of October 3, 1917, 
authorized July 15, 1932. 


Copyright for protection against republication. Journals 
of the American Medical Association and of other 
state medical associations may feel free to quote 
from this Journal whenever they desire 
merely giving credit to this publication. 


Address papers, discussions and scientific matter to 
John B. Thomison, M.D., Editor, P.O. Box 70, 
Nashville, Term. 37202 

Address organizational matters to Jack E. Ballentine, 
Executive Dir., 112 Louise Avenue, Nashville, Tenn. 37203. 

COMMITTEE ON SCIENTIFIC AFFAIRS 
HARRY A. STONE, M.D., Chairman, Chattanooga 
R. L. DeSAUSSURE, M.D., Memphis 
JOHN H. BURKHART, M.D., Knoxville 
HARRISON J. SHULL, M.D., Nashville 
CHARLES E. ALLEN, M.D., Johnson City 
JOHN B. THOMISON, M.D., Nashville 


FEBRUARY, 1973 


ecPiloficil/ 

The Carrot or the Stick 

During the months of November and Decem- 
ber, the TMA Committee on Continuing Edu- 
cation in conjunction with the Tennessee 
Hospital Association and the Tennessee Mid- 
South and Memphis RMP’s, conducted a series 
of seminars on the Professional Activity Study/ 
Medical Audit Program (PAS/MAP), and 
while they were reasonably well attended, 
physicians were for the most part conspicuous 
by their absence. 

Now it is neither the intent nor the desire of 
your committee, or of any of the other sponsors 
of the seminars, to try to sell PAS/MAP. The 
reason for all of our efforts is to try to impress 
on you, the physicians of Tennessee, the abso- 
lute necessity for an education program based 
on established and documented need. In the 
first place the Joint Commission on Accredita- 
tion requires it. But what should be more to 
the point is that only in this way can your own 


medical community develop its own program to 
answer its own needs for fulfilling what is the 
only real reason for continuing medical educa- 
tion (or any medical education at all, for that 
matter) : to alter our practice patterns in a way 
which will result in better care for our patients. 
It is what we all continually strive for. PAS/ 
MAP is one tool for accomplishing this. 

So much for the carrot. Now for the stick. 
PSRO’s are upon us, and will become more 
and more a part of our life. Whether we like it 
or not, somebody is going to be looking over 
our shoulder, looking at the quality of our 
medical care. Medical audit committees in hos- 
pitals are going to have to be more active. To 
do all that will be required is going to demand 
either an incredible amount of physician time or 
good organization. Properly organized, after the 
initial effort most of the work can be done by 
computers and lay personnel. 

Regardless of the system, the first order of 
priority is to establish criteria of good medical 
practice. These must be established locally, and 
by physicians. If we abrogate our responsibility 
here, it will be done for us, and done by com- 
mittees not necessarily friendly. Problem areas 
should be attacked first, and a data base is 
necessary to establish these areas. Standards 
must be very specific so as not to require medical 
records personnel to exercise medical judgment 
in computer input or retrieval. 

By establishing criteria and standards, it be- 
comes possible for computers to demonstrate 
practice patterns and trends of patient care. 
Rather than having audit committees make em- 
barrassing comparisons by a system of peer re- 
view, a physician can compare his own perfor- 
mance against established standards, and if he is 
assigned a number known only to himself, no 
one else can make such a comparison. There 
is then a basis for a rational program of con- 
tinuing education. 

There is an excellent film on Patient Care 
Appraisal, which has to do with the whole area 
of standards and criteria, prepared by the 
Washington State Medical Association, the 
University of Washington Office of Research in 
Medical Education, and the Washington/Alaska 
RMP. We anticipate that this film will be 
available to you for showing, on request to 
TMA, possibly at your medical society or 
hospital staff meeting. 

It seems to me we must move ahead in this 
area as rapidly as possible, and your continuing 


144 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


education committee stands ready to help you in 
any way possible. You have a great deal to 
gain; otherwise your loss could be great. 

J.B.T. 

Death on the Highway 

The publication of Dr. Francisco’s excellent 
paper on the implied consent law brings into 
focus two of this country’s major health prob- 
lems: death on the highway and alcoholism. To 
say that they bear a close relationship is to 
belabor the obvious, but there are some things 
about this relationship that bear closer scrutiny. 

A popular bit of cynicism says that there are 
lies, damned lies, and statistics. In order to pre- 
vent this being an ascending order of villainy, 
we must be very careful about how we handle 
statistics. While it certainly is true that the 
drinking driver is a deadly menace, and that at 
least 50% of traffic fatalities involve alcohol, it 
is probably not true that half of the fatal acci- 
dents are caused by drinking drivers. Although 
Dr. Francisco indicates he has figures which 
suggest it might be higher than 50%, published 
results indicate that on the contrary, at least 
10% of traffic fatalities involve drinking pedes- 
trians, not drivers, and in a significant number 
of fatal accidents involving alcohol the respon- 
sible party has not been drinking. 

I do not wish the preceding paragraph to 
be in any way misconstrued as suggesting that 
the problem of the drinking driver is not a 
serious one. Certainly the implied consent law 
is a great stride in the right direction. What I 
wish to do in this editorial is to question Dr. 
Francisco’s statement in the last paragraph of 
his paper that “without this kind of enforcement 
[of alcohol control laws] there is no convenient, 
reliable, or effective means presently available 
to reduce the annual fatalities occurring on 
the . . . highways of this state.” I certainly 
agree that this is true insofar as alcohol is the 
cause. What I wish to point out is that there are 
other perhaps equally pressing considerations 
requiring legislation and enforcement. 

First, there is the problem of the unsafe 
vehicle. One need only look out his window 
onto any street or highway and see automobiles 
and trucks which should have been sent long 
ago to the rendering factory. Vehicle inspection 
is inconvenient and expensive, hence it is not a 
popular platform for legislators. It is not nearly 
so inconvenient as being killed, nor as expensive 
as weeks or months in a hospital. 

Licensing laws are archaic, largely ineffective. 


and poorly enforced, again largely beeause to 
do the job right would be expensive and in- 
convenient. It is simply not reasonable to grant 
a license to drive at age 16 (or younger) and 
have it be valid for life, regardless of the de- 
terioration of the physical or mental status of 
the individual. Too often licenses are granted 
(to the very young or to the infirm) because 
of “hardship,” without considering responsibil- 
ity to the community. This is a widely abused 
facet of the hcensing law. Perhaps some thought 
should be given as to where individuals may 
drive — the granting of limited licenses. It re- 
quires all the alacrity anyone can muster, as 
well as a responsive, safe (inspected) vehicle, 
plus emotional and physical stability, to drive 
on the interstate system, where any accident is 
likely, because of the speeds involved, to be 
fatal. Any abridgement of driving privileges 
should be rigidly enforced — as should suspen- 
sion of licensure. This is widely ignored at 
present, because enforcement requires road- 
blocks, again expensive and inconvenient. 

The matter of impairment of reflexes and 
judgment needs to be expanded on, too. A 
0.10% alcohol blood level may be an all-round 
average figure as to what constitutes being 
“under the influence” of alcohol. We all know 
people, though, who “can’t hold their likker” — 
sniff the cork, and blotto! Often just as danger- 
ous are the drivers who are emotionally dis- 
turbed, who are taking other drugs, who are 
thinking of business deals or family troubles, or 
who are just plain tired and sleepy. These last 
are often in a hurry and “pushing it,” and fail 
to stop for rest and a cup of coffee. They may 
push on into eternity, often carrying others with 
them. The only safe (and responsible) attitude 
is not to drive under any of these circumstances, 
especially when drinking, which can compound 
the rest. 

Talking with passengers can constitute a 
serious hazard, and one of the greatest of this 
type hazard is “car pools” with young children, 
who often engage in horse play, which can 
completely distract the driver. 

Finally, and most importantly, there is the 
matter of individual responsibility. This cannot 
be legislated, but comes by example, and in- 
volves respect for law and a recognition of and 
respect for the rights of others. As defined by 
law in this state, the driving of an automobile is, 
in spite of much popular opinion to the contrary, 
a privilege, not a right. There is no room for 


FEBRUARY, 1973 


145 


rugged individualism on the highways, especial- 
ly when it involves hurtling a two ton projectile 
down a narrow concrete strip at speeds (often 
in violation of the law) of up to 100 miles per 
hour. We need to begin to teach this early to 
our children, not only by words, but by example. 

Any effort to reduce the highway traffic toll 
will be costly in time and money, and therefore 
unpopular. It seems to me that as physicians 
we play a crucial role, because we see every 
day the waste and the tremendous expense to 
the community, to individuals and to families 
in personal anguish, loss of life, and loss of 
productivity. It is up to us to be sure the com- 
munity has a clear view of this cost, and of the 
possible, nay imperative, remedial efforts, the 
cost of which is by comparison insignificant. 

J.B.T. 

The Cooper Quiz 

A couple of months back, when we began 
running “The Cooper Quiz” in the Journal, 
I asked for a reader response to it — whether 
you found it helpful, and wished it to be con- 
tinued. While the response has been 100% 
favorable, it has not been exactly overv/helming. 

This lack of response can be interpreted in 
one of three ways: 1) There is no wide support 
for such a feature; 2) few people want to take 
the time to write letters; or, 3), few people 
read the editorial pages, and consequently the 
request was lost on the majority. I hope it was 
for one of the latter reasons that I received so 
little response; vanity makes me prefer reason 
number 2). 

It is your editor’s desire to give the reader- 
ship what it wants. Any response to the ques- 
tion of a self-evaluation quiz will be appreciated. 

J.B.T. 


ERRATUM 

“THE COOPER QUIZ” (January, 1973 
Issue) Source of Answers: To Questions 
1-15, JAMA; to Questions 16-23, Archives 
of Internal Medicine; to Questions 24-32, 
New England Journal of Medicine, July, 
1972. 



ABERCROMBIE, EUGENE, Knoxville, died Decem- 
ber 3, 1972, age 79. Graduate of Vanderbilt Univer- 


146 


sity School of Medicine, 1916. Member of the 
Knoxville Academy of Medicine. 

CROSS, WILLIAM R., Knoxville, died December 22, 
1972, age 79. Graduate of Lincoln Memorial Univer- 
sity, 1916. Member of the Knoxville Academy of 
Medicine. 

MILLER, CLEO, Nashville, died January 7, 1973, age 
70. Graduate of Vanderbilt University School of 
Medicine, 1927. Member of the Nashville Academy 
of Medicine. 

REIFF, ROBERT, Elizabethton, died January 1, 1973, 
age 58. Graduate of University of Tennessee College 
of Medicine, 1949. Member of the Washington-Carter- 
Unicoi County Medical Association. 

SANDERS, LUCIUS CARL, Memphis, died Decem- 
ber 28, 1972, age 81. Graduate of University of 
Maryland, 1915. Member of the Memphis-Shelby 
County Medical Society. 

TUCKER, HARLIN, NashvUle, died December 10, 
1972, age 83. Graduate of Vanderbilt University 
School of Medicine, 1912. Member of the Nashville 
Academy of Medicine. 


neui fflcfflbcf/ 


The Journal takes this opportunity to welcome these 
new members of the Tennessee Medical Association. 

MAURY COUNTY MEDICAL SOCIETY 

Harold W. Ferrell, M.D., Columbia 
Harold H. Fry, Jr., M.D., Columbia 
John Richard Olson, M.D., Columbia 
Thomas R. White, M.D., Columbia 

WASHINGTON-CARTER-UNICOI COUNTY 
MEDICAL ASSOCIATION 

Richard Carver, M.D., Johnson City 
Jerry L. Gastineau, M.D., Elizabethton 
Charles S. Wassum, M.D., Johnson City 


pfooram/ cind neui/ of 
fiicdkol /ocielie/ 


Nashville Academy of Medicine 

U.S. Representative Richard Fulton was the fea- 
tured speaker at the November 14 meeting. He re- 
ported on medical and health legislation and other 
Federal programs. 

New Officers installed at the January 9 meeting in- 
cluded Dr. Frank Womack, President; Dr. George 
Holcomb, President-Elect; and Dr. Fred Rowe, Sec- 
retary-Treasurer. Dr. Robert Bomar and Dr. James 
W. Hays were elected to three-year terms on the 
Board of Directors and Dr. Gordon Peerman was 
elected Board Chairman. 

Knoxville Academy of Medicine 

The Academy met January 9 at the KAM Building 
Auditorium. The featured speaker was AMA past 
president Dr. Edward R. Annis, who spoke on such 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 






timely items as Professional Standards Review Or- 
ganization, Medical Foundations, National Health In- 
surance, HMO’s and AMP AC. The Academy invited 
members from a joint medical society to attend the 
meeting and to hold their monthly meetings in the 
KAM Building if they so desire. 

The Academy mourned the passing of Drs. Karl T. 
Sammons, David Hawkins, Harry Jenkins, and Eugene 
Abercrombie. 

Memphis-Shelby County Medical Society 

At its 84th Annual Meeting on December 12, 
officers for 1973 were installed. They included Dr. 
John B. Dorian, President; Dr. W. D. Dunavant, 
President-Elect; Dr. Wilford H. Gragg, Jr., Vice- 
President; Dr. John L. McGee, Jr., Secretary; Dr. 
Howard A. Boone, Treasurer; and Dr. Hugh Francis, 
Jr., Member-at-Large. 


iKiliencil neui/ 


THIS MONTH IN WASHINGTON 
(From Washington Office, AMA) 

New faces will be leading the nation’s major 
governmental health programs in President 
Nixon’s second term in office. 

At the helm of the Department of Health, 
Education and Welfare will be a new kind of 
secretary, a man with a reputation as a budget 
slasher with a zeal for protecting the taxpayers’ 
dollar. 

Caspar Weinberger will be the first HEW 
secretary schooled in the money world of fiscal 
prudence. Nicknamed “Cap the Knife,” the 
appointment of Weinberger to run the govern- 
ment’s social welfare, health and educational 
programs perhaps marks the President’s most 
daring cabinet decision. 

Selection of the 55-year-old California lawyer 
seems to be proof of the President’s intention 
to reverse the tide of heavier federal welfare 
spending, to channel more money and responsi- 
bilities to states and locafities, and to steer 
away from the European welfare state concept. 

Weinberger will be moving over to HEW from 
the post of director of the White House Office 
of Budget and Management, a cabinet post but 
one where Weinberger was able to function in 
the comparative anonymity he has preferred to 
date. At HEW he will be thrust into the lime- 
light and in short time will become one of the 
best known public figures in the nation. 

Despite its reputation as a wrecker of reputa- 
tions, the HEW Department secretaryship has 


served most of its occupants well. Outgoing 
Secretary Elliot Richardson was elevated to the 
more powerful and prestigious post of defense 
secretary. Abraham Ribicoff, who despaired of 
presiding over the “can of worms” at HEW, 
found his tenure there no handicap in his race 
for the Senate. 

Ribicoff will be one of the senators present 
at the Senate Finance Committee confirmation 
hearing in January on Weinberger’s nomination. 
The confrontation between Ribicoff and Wein- 
berger promises to be an interesting exchange 
as Weinberger outlines his views on his new 
position and Ribicoff contributes his advice. 

Few fireworks are expected at the confirma- 
tion hearing. No committee on Capitol Hill is 
more conscious of the waste and duplication 
at HEW than Senate Finance which has a mem- 
bership considerably more conservative than 
the Senate as a whole. 

Weinberger undoubtedly will give a good pic- 
ture of his general views and philosophies dur- 
ing his appearance. If he follows tradition, a 
more detailed explication will be made at a 
news conference after he is confirmed and 
sworn in as HEW Secretary. 

Weinberger is no stranger to the operations 
of HEW. At the Budget Office he became well 
acquainted with the finances of HEW and in- 
deed in tandem with the White House exerted 
extraordinary fiscal powers over federal health 
programs. 

Weinberger’s appointment may end a chafing 
dichotomy between the White House staff and 
the White House OMB on the one hand and 
HEW on the other. As a loyal Administration 
servant, Richardson was willing to put up with 
the situation while it lasted but it is doubt- 
ful he would have remained compliant much 
longer. 

There’s little question that Weinberger is 
going to propose HEW cuts that will enrage 
some congressmen, but on the whole the ex- 
pectation here is that he won’t be easily cate- 
gorized except perhaps as a pragmatist. 

He has noted for example, that more than 
71 per cent of federal expenditures are for 
things over which the Administration has no 
control — such items as interest on the national 
debt. Medicare, and veterans compensation. 

^ ^ 

John G. Veneman, the number two man at 
HEW, has also announced his resignation. 


FEBRUARY, 1973 


147 







SCANDIIWIAN ADVENTURI 


t-^ I -5t?v.., V :. 

#1 M ^ 





Departing Memphis and Nashville— August 3, 1973 

TENNESSEE MEDICAL ASSOCIATION 

Send $100 deposit to 112 Louise Ave., Nashville, Tenn. 37203 


m 



presumably with an eye to running for 
lieutenant governor of California. 

Veneman was a frequent spokesman for 
HEW before the Congress before he became 
under secretary of Health, Education and Wel- 
fare in 1969 at the request of then-HEW 
Secretary Robert H. Finch. 

Frank C. Carlucci, the former director of 
the Office of Economic Opportunity who now 
is deputy budget director is in line to replace 
Veneman. Carlucci was number two man in 
the Office of Management and Budget to 
Caspar Weinberger. 

Carlucci’s place in the Office of Management 
and Budget will be taken by Fred Malek, the 
Nixon Administration troubleshooter who now 
heads recruiting efforts in the reshuffle taking 

place before the President’s second term. 

^ ^ 

Also departing from the command line-up 
at HEW are Assistant Secretary for Health and 
Scientific Affairs, Merlin DuVal, M.D., and 
Vernon Wilson, M.D., chief of Health Services 
and Mental Health Administration, the largest 
operating branch of HEW. 

Dr. DuVal, whose resignation comes 16 
months after his appointment, returns to the 
University of Arizona where he will be vice- 
president for medical affairs. Dr. Wilson re- 
turns to the University of Missouri Medical 
School after guiding HSMHA since May, 1970. 

Dr. DuVal believes that the administration 
of health programs have been tightened and 
control over the various health agencies 
strengthened during his tenure. He gives 
HEW Secretary Elliot Richardson credit for 
moving in this direction, though he helped 
institute much of the change. DuVal also sig- 
nificantly broadened HEW’s health liaison 
with other federal departments. 

Dr. Wilson carried out a sweeping reorgani- 
zation of HSMHA, focusing management in his 
office and among his deputies. He was given 
high marks for bringing order out of an 
amorphous spread of agencies. 

In neither case were the resignations of Du- 
Val and Wilson the result of any pressure from 
above. The x\dministration wanted both phy- 
sicians to stay on. 

The departures of DuVal and Wilson will 
give new HEW Secretary Caspar Weinberger 
two important health slots to fill. These slots 
in all likelihood will not be filled until after 
new HE\\' Secretary Caspar Weinberger is 


confirmed by the Senate and sworn into office, 

probably in January. 

^ ^ ^ 

The firing of Robert Q. Marston, M.D., 
Director of the National Institutes of Health 
and the only top holdover from the Johnson 
Administration, prompted some angry reaction 
from Congress and stunned surprise from the 
medical academic community. No reason was 
given for the President’s acceptance of Dr. 
Marston’s pro-forma resignation. 

Rep. Paul Rogers (D-Fla.), head of the 
House Health Subcommittee, commenting on 
the Marston firing, said “every top health ad- 
ministrator now has either resigned or been 
relieved. This latest announcement precludes 
any hope of continuity in the health field on 
the federal level with more than a dozen pieces 
of health legislation coming up.” 

Dr. Marston had built strong ties with Con- 
gress and the academic research community 
since he succeeded James Shannon, M.D., at 
NIH in 1968. NIH’s appropriations rose to 
$2.1 billion with broad new programs on cancer 
and heart research added in the past two years. 

John Twiname, Administrator of HEW’s 
Social Rehabilitation Service (Medicaid), also 
had his pro-forma resignation accepted by the 
President. 

* * 

There was no great surprise, however, when 
the White House announced the resignation of 
Jesse Steinfeld, M.D., as Surgeon General of 
the Public Health Service. 

The 45-year-old Dr. Steinfeld, a career PHS 
officer who has held the Surgeon General’s 
post since 1969, may be the last man to fill 
the position. The Administration has made 
clear its intent to abolish the PHS’s Commis- 
sioned Corps. In the past several years the 
Surgeon General has been divested of most of 
his authority, and the hopes of the PHS Com- 
missioned Corps that it might be revived have 
faded. 

With the massive resignations and firings, 
only Charles Edwards, M.D., Food and Drug 
Administration Commissioner, now remains of 
the old guard. 

H! 

After 16 months of deliberation marred with 
dissension, a federal advisory commission has 
decided not to recommend any single solution 
to the problem of medical malpractice insur- 
ance. The gist of the divided commission’s 


FEBRUARY, 1973 


149 


report to HEW is to explore a variety of ways 
to modify malpractice laws at the state level. 

Nothing that will be submitted in the com- 
mission’s final report to the HEW secretary by 
the first of the year apparently would have 
much effect on the rising costs of malpractice 
insurance, the growing number of claims, and 
the resulting impact on physician’s fees. 

Any hopes that some sort of a consensus 
might be attained in the year and half since 
the commission’s formation were dashed at its 
final meeting when members aired their dis- 
agreements over various aspects of the report. 

The clash for the most part involved spokes- 
men for physicians and insurance companies 
on the one hand, and lawyers’ groups and con- 
sumer organizations on the other. A strong 
minority report was expected challenging the 
brunt of the final findings. 

The report by the 21 -member committee is 
strictly advisory. The HEW secretary is not 
required to make any legislative proposals on 
the basis of it. Unless HEW has some legis- 
lative recommendations in the works, it ap- 
pears doubtful the Administration will seek any 
changes in malpractice statutes as part of its 
legislative health package this year. 

One of the more controversial findings of 
the commission was the suggestion that the 
contingent fee system actually hinders litigants 
with small malpractice claims and a suggestion 
that there should be public legal assistance for 
those with small claims. The report did not 
recommend abolishment of the contingent fee 
system. 

Carl A. Hoffman, M.D., AMA President 
and a member of the commission, has sub- 
mitted to the commission some forty pages of 
comments that address themselves to a number 
of shortcomings contained in the report. 

Hs ^ ^ 

The director of the Federal Drug Adminis- 
tration’s Bureau of Drugs has charged before 
a Senate subcommittee that physicians are over- 
prescribing antibiotics, resulting in an increased 
number of “resistant strains of bacteria and an 
increased number of superinfections.” 

“There may be 100 to 300 thousand cases 
each year of blood poisoning from superin- 
feetions, of which 30 to 50 per cent are fatal,” 
aceording to testimony before the Senate Small 
Business’ Subcommittee on Monopoly by Henry 
E. Simmons, M.D. 

Harry F. Dowling, M.D., emeritus professor 


of medieine, University of Illinois, said “it is 
doubtful the average person has an illness that 
requires treatment with an antibiotic more often 
than once every five or ten years.” Antibiotic 
production has needlessly increased, however, 
in the past ten years, he said. 

The physician’s fear of failure to help his 
patients — stronger than his fear of complica- 
tions — motivates him to prescribe antibiotics, 
suggested Calvin M. Kunin, M.D., of the Uni- 
versity of Wisconsin School of Medicine. 

^ ^ ^ 

More than 1300 persons died from narcotics 
abuse in New York City in 1972, that city’s 
chief deputy medical examiner told a confer- 
ence on the “Medical Complications of Drug 
Abuse” sponsored in Washington by the AMA’s 
Committee on Alcoholism and Drug Depen- 
dence. 

Michael M. Baden, M.D., said that heroin 
addiction has become the leading cause of 
death among persons between the ages of 15 
and 35 in New York. At the same time, more 
than 30 per cent of narcotic deaths in the 
city have been associated with methodone use 
— both legal and illegal, Dr. Baden said. 

White House physician William M. Lukash, 
M.D., served as coordinator of the all-day 
conference that attracted more than 500 phy- 
sicians to the nation’s capital to hear leading 
drug experts describe the problems involving 
addicts. 

Dr. Baden told the conference that during 
the past decade, the growing abuse of drugs 
has been reflected by a “marked increase” in 
narcotic deaths (from 109 in 1960), a de- 
crease in the median age of death from 31 
in 1960 to 23 today, and a change in the 
pattern of drug abuse from heroin alone to 
multiple drugs, most recently methodone. 

“The drug addict seen today in the emer- 
gency room for an ‘overdose’ cannot be pre- 
sumed to have taken only heroin — or heroin 
at all,” Dr. Baden told the conference. “We 
see too many addicts at autopsy who were 
sent home after ‘responding’ to an injection 
of nalorphine and died shortly thereafter be- 
cause methodone or barbiturates had also been 
taken. 

J. Willis Hurst, M.D., recent past president 
of the American Heart Association, told the 
conference that a preliminary survey indicates 
that drug abusers’ contaminated needles are 


150 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


now one of the leading causes of bacterial 
endocarditis in the nation. 

A panel of specialists on the liver disclosed 
that the amount of hepatitis associated with 
drug abuse is still rising but that many drug 
users display no symptoms of the disease and 
thus are able to sell their diseased blood to 
collection centers. 

^ ^ ^ 

Methodone will be distributed only through 
hospital pharmacies, approved maintenance 
programs, and certain drug stores in rural areas, 
under newly tightened regulations announced 
by the Food and Drug Administration. 

Effective immediately, FDA is requiring pa- 
tients to have been addicted to heroin at least 
two years before participating in a methodone- 
maintenance program. Enrollment of minors 
will be limited. 

Patients 16 to 18 may remain in current 
programs, FDA said, but no additional minors 
may be admitted unless a consent form is signed 
by a parent, legal guardian, or a state-desig- 
nated authority. 

The new rules require patients of treatment 
centers to take the drug daily at the center, 
under observation, for the first three months. 
If they show satisfactory progress, they will 
be allowed to take home two-day supplies, 
and after two years, three-day supplies. 

The new restrictions are necessary to curb 
“a growing problem of abuse and diversion 
of methodone, said FDA. 

While announcing the unique closed system 
of methodone distribution, FDA also said 
methodone marketing permits of eight drug 
companies will be revoked. 

“It is not in the public interest, either to 
withhold the drug from the market until it has 
been proved safe and effective under all con- 
ditions,” said FDA Commissioner Charles 
C. Edwards, M.D., “or to grant full approval 
for unrestricted distribution, prescription, dis- 
pensing or administration of methodone.” 


i|iedi€<il neui/ 
in tennc/zee 


Westenberger Named to Nashville 
Academy of Medicine Position 

John M. Westenberger has been named 
Executive Director of the Nashville Academy of 


Medicine & Davidson County Medical Society. 
He succeeds Jack Drury, the Academy’s 
executive since 1954, who will continue to serve 
on a part-time basis to organize and activate 
the Davidson County Foundation for Medical 
Care, a medical and hospital service project 
under development by the Academy. 



Westenberger 



Drury 


Westenberger, 32, assumes the executive post 
after two years as Executive Assistant and Field 
Representative with the Tennessee Medical As- 
sociation. He previously was the Director of 


FEBRUARY, 1973 


151 




Development and Public Relations at Tennessee 
Wesleyan College in Athens and a photo- 
journalist with the U.S. Naval Pacific Fleet 
Combat Camera Group. 

A graduate of Birmingham-Southern College, 
Westenberger is an accredited member of the 
Public Relations Society of America, Middle 
Tennessee Chapter, chairman of the local 
Birmingham-Southern alumni chapter, and a 
member of the administrative board of Belle 
Meade United Methodist Church. He is listed 
in the 1969 edition of Outstanding Young Men 
of America, U.S. Jaycees. 

Drury, prior to joining the Academy staff, was 
a member of the Nashville Banner’s editorial 
staff for 18 years serving as City Editor from 
1942 to 1954. In 1938 he received a national 
award for a series of newspaper articles on 
traffic safety. 

Active in community affairs, he is a mem- 
ber and former board member of the Exchange 
Club of Nashville, a board member of the Bill 
Wilkerson Hearing & Speech Center and the 
Nashville Eye Bank, and on the Blood Recruit- 
ment Committee of the Red Cross Blood Center 
where he is a 9-gallon donor. 

The Nashville Academy of Medicine is com- 
posed of about 700 members representing 35 
fields of practice and including attending 
physicians at 17 hospitals and faculty members 
at Nashville’s two medical schools. 

John R. Coles Named 
To TMA Executive Staff 

John R. Coles has been appointed Executive 
Assistant for Legislation, according to Jack E. 
Ballentine, Executive Director of TMA. 

Coles will serve TMA physician members 
and state legislators by assisting in the adminis- 
tration of the Association’s legislative program. 
Also, he will staff several TMA committees 
including the Liaison Committee to the State 
Department of Public Health. 

Coles, 27, comes to TMA from GENESCO 
where he served as Assistant Manager of the 
Military and Commercial Footwear Export divi- 
sion. He is a 32-degree Scottish Rite Mason 
and Shriner, and a member of the Masonic 
Lodge Observance 686, Nashville Area Junior 
Chamber of Commerce, and Harpeth Presby- 
terian Church. 

A graduate of Columbia Military Academy 
and Belmont College, Coles is married to the 

152 


former Charlotte White of Franklin and resides 
at 1933 Rosewood Valley Drive in Brentwood. 




Coles 


pftf/ofMil neui/ 


DR. T. K. BALLARD, Jackson, has been elected 
chairman of the Tennessee Public Health Council, 
the major policy body for the State Department of 
Public Health. Dr. Ballard succeeds DR. J. KELLEY 
AVERY of Union City. 

DRS. LLOYD T. BROWN, Gallatin, and PAUL L. 
JOURDAN, Knoxville, have been elected active mem- 
bers in the American Academy of Family Physicians. 

DR. HUGH DON CRIPPS, Smithville, has been 
elected to the Board of Directors of the First National 
Bank of Smithville. 

DR. THOMAS A. CURREY, Memphis, has assumed 
the presidency of the St. Joseph Hospital Medical 
staff in Memphis. He succeeds DR. PAUL 
WILLIAMS as President. 

DR. OLIVER DeLOZIER, Knoxville, has been elected 
president of the Knoxville Academy of Surgery suc- 
ceeding DR. ABNER GLOVER. Others elected were 
DR. CHARLES SMELTZER, vice-president, and 
DR. HUGH A. BLAKE, secretary-treasurer. 

DR. JOHN B. DORIAN, Memphis, was installed as 
President of the Memphis and Shelby County Medical 
Society at its 84th Annual Meeting on December 12. 

DR. LLOYD C. ELAM, Nashville, has been named 
Vice-Chairman of the State Comprehensive Health 
Planning Council. Dr. Elam also serves as Chairman 
of the Tennessee Rhodes Scholarship Selection Com- 
mittee. 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 





DR. TAYLOR FARRAR, Shelbyville, has accepted a 
position with the State Department of Public Health 
effective January 1, 1973. 

DR. JAMES H. FLEMING, NashviUe, serves as Presi- 
dent and chairman of the executive committee of 
Nashville's newest hospital. West Side Hospital. 

DR. EUGENE W. FOWINKLE, Nashville, Tennessee 
Commissioner of Public Health, was the speaker at 
the University of Tennessee Medical Units graduation 
in December. 

DR. JERRY FRANCISCO, Memphis, Shelby County 
and State Medical Examiner, has received a grant from 
Memphis Regional Medical Program to engage in the 
gathering and analysis of death statistics. 

DR. C. J. HARKRADER, JR., Bristol, has announced 
his candidacy for city council from district number 
two. 

DR. ALLYN M. LAY, Mt. Pleasant, who has prac- 
ticed medicine there for the past ten years, has left 
to enter specialty training. 

DR. JACK M. MOBLEY, Knoxville, has been elected 
chief of staff of the Presbyterian Hospital. He suc- 
ceeds DR. MARK FECHER. 

DR. H. A. MORGAN, JR., Lewisburg, director of the 
South Central Region of the Tennessee Department 
of Public Health, resigned that position effective 
November 15. 

DR. HENRY PACKER, Memphis, chairman of pre- 
ventive medicine at University of Tennessee Medical 
Units retired effective December 31. 

DR. JAMES W. PATE, Memphis, head of the thoracic 
surgery at the University of Tennessee Medical Units 
has been installed as president of the Southern 
Thoracic Surgical Association. 

DR. K. J. PHELPS, Lewisburg, has been elected Chief 
of Staff of the Consolidated Lewisburg Community 
Hospital Medical Staff. 

DR. JOHN PURVIS, Concord, suffered head cuts 
and leg injury in an automobile accident on December 
22 . 

DR. ROBERT E. RICHIE, Vanderbilt Medical School, 
Nashville, recently demonstrated the preservation of 
the kidney in preparation for transplantation during 
‘'Operation Heartbeat-Science Explorers Day” held in 
Nashville. 

DR. EARL E. ROLES, JR., Tullahoma, has been 
elected Chief of the Harton Hospital medical staff. 
DR. FENTON SCRUGGS, Cleveland, has announced 
that seven physicians would be moving in 1973 to 
Cleveland to practice as a result of a concentrated 
recruiting program. 

DR. CURTIS SEXTON, Lake City, recently partici- 
pated in local ceremonies at McGhee Tyson Air Base. 
Dr. Sexton is one of the groups’ physicians. 

DR. ALEX B. SHIPLEY, KnoxviUe, Regional Health 
Director, has announced a series of venereal disease 
clinics to be held in Cocke County at the Cocke 
County Health Department in an effort to curb the 
upswing in venereal diseases which is spreading to 
rural as well as urban areas. 



FEBRUARY, 1973 


153 



DR. CHARLES A. TRAHERN, Clarksville, appeared 
on the program of an AMA sponsored Rural Health 
Workshop held in Atlanta on January 11. 

DR. C. RICHARD TREADWAY, Nashville, Com- 
missioner of Mental Health, and DR. WILLIAM H. 
TRAGLE, Nashville, Central State Superintendent, 
have announced a second drug and alcohol rehabilita- 
tion center at Central State Hospital in Nashville. 
DR. JULIAN K. WELCH, Brownsville, and DR. 
JOAN BRUCE WOODS, Oak Ridge, have been 
named recipients of the 1972 Physicians Recognition 
Award by the American Medical Association. 

DR. NAT T. WINSTON, Nashville, recently spoke 
at a Kiwanis Luncheon held at the Sheraton-Peabody 
in Memphis. He also spoke at a recent meeting of 
the National Association of Accountants at the Read 
House in Chattanooga. 

DR. GEORGE A. ZIRKLE, JR., Knoxville, has been 
re-elected Secretary of the Tennessee Public Health 
Council. 


onnouncemcnl/ 


CALENDAR OF MEETINGS 

STATE 

April 11-14 Tennessee Medical Association, An- 
nual Meeting, Sheraton-Peabody Ho- 
tel, Memphis 


NATIONAL 

March 29-30 AMA National Conference on Rural 
Health, 26th, Statler-Hilton, Dallas 

April 1-4 American College of Surgeons, Spring 

Meeting, Hilton and Americana Ho- 
tels, New York 


April 2-7 

American College of Radiology, St. 
Francis Hotel, San Francisco 

April 3-5 

American Academy of Facial Plastic 
and Reconstructive Surgery, Chase 
Park Plaza Hotel, St. Louis 

April 6-8 

American Society of Internal Medi- 
cine, Palmer House, Chicago 

April 9-12 

American Academy of Pediatrics, 
Spring Session, Sheraton-Boston Ho- 
tel, Boston 

April 9-13 

American College of Physicians, Con- 
rad Hilton, Chicago 

April 16-18 

American Association for Thoracic 
Surgery, Fairmont Hotel, Dallas 

April 16-19 

American Association of Neurological 
Surgeons, Century Plaza Hotel, Los 
Angeles 

Aprff 23-28 

American Academy of Neurology, 
Sheraton-Boston Hotel, Boston 

April 25-27 

American Surgical Association, Cen- 
tury-Plaza Hotel, Los Angeles 

May 2-5 

American Gynecological Society, 
Broadmoor Hotel, Colorado Springs 

May 11-12 

American Association of Clinical 
Urologists, New York Hilton Hotel, 
New York 

May 13-17 

American Urological Association, 
New York Hilton Hotel, New York 

May 16-20 

American Pediatric Society, Hilton 
Hotel, San Francisco 

May 21-24 

American College of Obstetricians 
and Gynecologists, Americana Hotel, 
Bal Harbour, Fla. 

May 21-24 

American Thoracic Society, Staffer 
Hilton Hotel, New York 



conliiiiikio 

iiiliiccilioA oppbfliMiilic# 



University of Tennessee CME Courses 

The following continuing education courses are 
being offered by the University of Tennessee College 
of Medicine during 1973: 

Date: Course: 

March 5-9 Fundamentals of Otolaryngology 
March 17-18 Pediatric Anesthesia 


May 9-11 
May 9-12 


May 14-18 
May 20-23 


Pulmonary Disease 

Clinical Electrocardiography (Paris 
Landing State Park Inn, Buchanan, 
Tennessee) 

Intensive Review of the Science of 
Anesthesiology 

Basic Principles of Rhinoplasty 


March 26-31 
April 2-3 
April 12-13 


General Review Course for the Family 
Physician 

A Clinical Approach to Common Skin 
Problems 

Conference on the Exceptional Child 


Vanderbilt University CME Courses 

Date Title, Location, Program Coordinator 


March 8 Death and Dying, Location to be an- 

nounced, Mr. Robert Reber 


154 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 




March 16-17 
March 23-24 

April 4-6 
April 27-28 

May 23-24 

July 11-12 
Sept. 19-21 

Sept. 26-28 

Oct. 10-12 

Oct. 25-27 


Renal Insufficiency, University Club of 
Nashville, Earl Ginn, M.D. 

2nd Annual Dragstedt Surgery Sym- 
posium, Underwood Auditorium, Van- 
derbilt, John Foster, M.D. 

Critical Care, (co-sponsor, American 
College of Physicians), Underwood 
Auditorium, Vanderbilt, Ms. Norma 
Shephard 

Pros and Cons of Group Practice, 
(Organization Alternatives in Medical 
Practice), University Club of Nash- 
ville, Paul Slaton, M.D. 

13th Annual Seminar in Psychiatry, 
Location to be announced, Vergil 
Metts, M.D. 

Ky. Med. Assn., Annual Meeting 
Lake Barkley, Kentucky 

Endocrinology (American College of 
Physicians) 

Underwood Auditorium, Vanderbilt, 
Grant W. Liddle, M.D. 

The Injured Child (American Academy 
of Orthopedic Surgeons) 

Underwood Auditorium, Vanderbilt, 
John Connolly, M.D. 

Hypertension (American College of 
Cardiology) 

Underwood Auditorium, Vanderbilt, 
Lawrence Grossman, M.D. 

Child Neurology 

Underwood Auditorium, Vanderbilt, 
Gerald Fenichel, M.D. 


ACP Regional Meetings and 
Postgraduate Courses 

1973 REGIONAL MEETINGS 

Loiiisiana-Mississippi Regional Meeting, American 
College of Physicians, Feb. 23-24, Royal Sonesta 
Hotel, New Orleans, La. INFO; A. Sheldon Mann, 
M.D., 1514 Jefferson Highway, New Orleans, La. 
70121. 

Missouri Regional Meeting, American College of 
Physicians, Feb. 23-24, Ramada Inn, St. Louis, Mo. 
INFO: Thomas F. Frawley, M.D., St. Louis Univ. 
Hospital, 1325 South Grand Blvd., St. Louis, 
Missouri 63104. 

Alabama Regional Meeting, American College of 
Physicians, March 2-3, Grand Hotel, Pt. Clear, Ala- 
bama. INFO: Alwyn A. Shugerman, M.D., 1815 11th 
Avenue, Birmingham, Ala. 35205. 

South Carolina Regional Meeting, American College 
of Physicians, March 9-10, Matador Motor Inn, Co- 
lumbia, S. C. INFO: Vince Moseley, M.D., 51 E. 
Bay, Charleston, S. C. 29401. 

Virginia Regional Meeting, American College of 
Physicians, March 16-17, Williamsburg Inn, Williams- 
burg, Va. INFO: W. Taliaferro Thompson, Jr., M.D., 
4602 Sulgrave Rd., Richmond, Va. 23221. 



economy 



BRISTOL LABORATORIES 
Division of Bristol-Myers Co. 
Syracuse, N.Y. 13201 


FEBRUARY, 1973 


155 



1973 POSTGRADUATE COURSES 


These courses are arranged through the cooperation 
of the directors and the institutions involved. Registra- 
tions forms and requests for information are to be 
directed to: Registrar, Postgraduate Courses, Ameri- 

can College of Physicians, 4200 Pine Street, Phila- 
delphia, Pa. 19104. Tuition Fees: ACP Members and 
Fellows, $80; Nonmembers, $125; Associates, $40; 
Other Residents and Research Fellows, $80. 


Date 

Feb. 26- 
Mar. 2 


Mar. 5-8 


Mar. 5-8 


Mar. 12-16 


Mar. 14-16 


Mar. 19-23 


Mar. 22-24 


Mar. 26-30 


Apr. 4-6 


Apr. 24-27 


Apr. 25-27 


Apr. 25-27 


May 16-18 


Title and Location 

CLINICAL GASTROENTEROLOGY, 
University of Michigan Medical Center, 
Ann Arbor, Mich. 

PROBLEMS OF INTERNATIONAL 
HEALTH, Naval Dept., San Diego, 
Calif. 

MODERN NEUROLOGICAL DIAG- 
NOSIS AND THERAPY, University of 
Miami School of Medicine, Miami, Fla. 

INFECTIOUS DISEASES, University of 
Maryland School of Medicine, Baltimore, 
Md. 

CLINICAL PHARMACOLOGY: RA- 
TIONAL BASIS OF THERAPEUTICS, 
Univ. of California School of Medicine, 
San Francisco, Calif. 

FOUR AND ONE-HALF DAYS OF 
INTERNAL MEDICINE: WHAT’S 

NEW? University of Alabama School of 
Medicine, Birmingham, Ala. 

CLINICAL RECOGNITION AND 
MANAGEMENT OF HEART DIS- 
EASE — 1973, University of Arizona 
Medical Center, Tucson, Ariz. 

CARDIOLOGY — 1973 — TOPICS OF 
CURRENT INTEREST, Mount Sinai 
School of Medicine, New York, N.Y. 

RECENT ADVANCES IN DIAGNOSIS 
AND MANAGEMENT OF PULMO- 
NARY DISEASE, Virginia Mason Med- 
ical Center, Seattle, Wash. 

PULMONARY DISEASE, University of 
Pennsylvania School of Medicine, Phila- 
delphia, Pa. 

HEPATOBILIARY DISEASE IN CLIN- 
ICAL PRACTICE, University of Cali- 
fornia, San Francisco, Calif. 

ADVANCES IN DIAGNOSIS AND 
MANAGEMENT OF INFECTIOUS 
DISEASE, University of Wisconsin, 
Madison, Wis. 

THE RHEUMATIC DISEASES— 
CLINICAL AND IMMUNOLOGICAL 
ASPECTS, University of Texas South- 
western Medical School, Dallas, Tex. 


May 16-18 CLINICAL AUSCULTATION OF THE 
HEART, Georgetown University Hospi- 
tal, Washington, D.C. 

May 21-25 INTERNAL MEDICINE: CURRENT 
CONCEPTS OF CLINICAL PROB- 
LEMS, University of Cincinnati Medical 
Center, Cincinnati, Ohio. 

May 21-25 INTENSIVE CARE UNITS, St. Vin- 
cent’s Hospital and Medical Center of 
New York, New York, N.Y. 


May 29- RECENT ADVANCES IN ENDO- 
June 1 CRINOLOGY AND THEIR CLINICAL 
APPLICATIONS, Royal Victoria Hospi- 
tal, Montreal, Que., Can. 

June 4-8 HEMATOLOGY, University of Wash- 
ington School of Medicine, Seattle, Wash. 

June 13-15 ONCOLOGY AND CHEMOTHER- 
APY, University of Southern California, 
Los Angeles, Calif. 

June 18-22 CLINICAL ASPECTS OF BLOOD 
TRANSFUSION, Michigan State Univ., 
East Lansing, Mich. 

June 25-29 ADVANCES IN INTERNAL MEDI- 
CINE: RECENT PERSPECTIVES, 

1973, Banff, Alta., Can. 


Three Days of Cardiology 

“Three Days of Cardiology for Physicians” 
will be held at Shreveport, Louisiana on March 
1, 2, and 3, 1973. 

The meeting is co-sponsored by the Council of 
Clinical Cardiology of the American Heart As- 
sociation, Louisiana State University Medical 
School — Shreveport, and the Louisiana Heart 
Association. 

The theme of the meeting is “Cardiovascular 
Emergencies.” 

Symposium on Pediatric Radiology 

This three-day symposium to be held May 
2-4, 1973 will deal with many practical prob- 
lems in the diagnosis of abdominal, chest, and 
skeletal disease in childhood. A distinguished 
guest and University of Kentucky faculty will 
join in presenting the conference, organized to 
meet the need of practicing pediatricians and 
radiologists. 

Direct inquiries to: Frank R. Lemon, M.D., 
Continuing Education, College of Medicine, 
University of Kentucky, Lexington, Kentucky 
40506. 


156 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 





of public heollh 



Health Data for Decision Making 

The Tennessee Department of Public Health 
is the recipient of a Federal-State-Local Health 
Statistics System grant which should dramati- 
cally improve the collecting and reporting of 
health statistics in the State. The Department 
is one of eight agencies throughout the country 
funded for the first year of this program. The 
funding will enable the Department to conduct 
certain special studies. Subjects to be under- 
taken under the present funding include a 
health interview survey, an inventory of licensed 
health manpower and an inventory of health 
facilities. 

The Health Department in Tennessee has a 
long history of maintaining high quality 
statistical information. Types of information 
presently processed include vital statistics; 
morbidity statistics; data from Crippled Chil- 
dren’s Service, immunization programs, indigent 
hospitalization, hospitals, selected health man- 
power and disease-specific information for tuber- 
culosis, venereal disease, and accidents. The 
newly funded statistical project will build upon 
a firm statistical foundation already established 
in the state. 

HEALTH INTERVIEW SURVEY 

Designed to meet one of the basic tasks and 
responsibilities of state and local health agencies, 
the Health Interview Survey will determine the 
major health needs of people by communicating 
directly with them. Many approaches and pro- 
longed periods of time will be needed to de- 
termine total health needs, but the health 
survey is one source of basic information. To 
identify areas where greatest deficiencies exist, 
health needs and service patterns will be com- 
pared to available manpower and facilities. 

Solutions to community health problems in 
Tennessee will vary by type of problem and 
regional differences. Thus estimates will be 
made for the state and five sub-regions of the 
state. The sub-regions will be: 

1. The four counties with cities of 100,000 or more 
population 

2. The 22 counties with cities of 10,000 to 99,999 
population 


3. Counties without a city of 10,000 population in 
the eastern portion of the state 

4. Counties without a city of 10,000 population in 
the middle region of the state 

5. Counties without a city of 10,000 population in 
the western portion of the state 

In order to make statistically sound esti- 
mates, a probability sample of approximately 
5,000 households will be selected. Estimating 
procedures and processing will be conducted so 
that it will be impossible to identify specific 
individuals. Types of information to be col- 
lected will include the following: 

Age, race and sex of members of the households 
Income and education of heads of households 
Prevalence of medical and psychiatric conditions 
as identified by the people themselves 

Types of medication or appliances used by the 
population 

Proportion of the population using tobacco, 
alcohol, or other substances 

Geographic location of sought medical services 
Types of medical practitioners delivering health 
services 

Methods of payment for health care 
Regular sources of health services 
Additional types of medical services desired by 
the population 

Opinions of the respondents on the quality of 
medical care received by the households 

HEALTH MANPOWER INVENTORIES 
Licensed health manpower is a major resource 
for the delivery of health services. In order to 
plan for health services it is necessary to know 
the characteristics and distribution of this man- 
power. Limited information is available for 
professions which are licensed under the Li- 
censing Board for the Healing Arts. These in- 
clude physicians, dentists, chiropractors, osteo- 
paths, optometrists, dispensing opticians, 
psychologists, psychological examiners, physical 
therapists and nursing home administrators. For 
other licensed health manpower, the types and 
availability of data vary greatly. Included are 
veterinarians, water system operators, profes- 
sional environmentahst, pharmacists, podiatrists, 
dental hygienists, dental assistants, registered 
nurses, licensed practical nurses, and laboratory 
personnel. 

The project’s manpower staff will develop a 
system of registration and record keeping ap- 


FEBRUARY, 1973 


157 


plicable to all licensed health professions. 
Statistical information on health manpower will 
be collected as a part of registration, licensing, 
and renewal procedures. Since this information 
will be based on licensing records, the rules of 
confidentiality governing licensing procedures 
will apply. Tabulations will be made, not only 
on a statewide basis, but for planning regions 
and counties. 

Types of information maintained will include 
state and county of practice, race, sex, date of 
birth, basis for licensing, professional school 
attended, and specialties within the profession. 

HEALTH FACILITIES INVENTORIES 

Health facilities are another major resource for 
the delivery of health services. Information on 
health facilities have been collected for many 
years by the Tennessee Department of Public 
Health through the Certification and Licensure 
Division, and by the Health Care Facilities, 
Survey and Construction Division. During the 
last few years, this has been a joint project of 
the Department, the Tennessee Hospital As- 
sociation, and regional Comprehensive Health 
Planning agencies. 

The purpose of the Facilities Inventory will 
be to improve the quality of information col- 
lected and the timeliness of the information, 
and to mechanize the processing in order to 
have statistical information in a more retrievable 
form. Uniform information will be available to 
state and local agencies. The information can 


also be provided to federal agencies and others. 
It is hoped that ultimately one collection source 
may be able to answer questions needed by 
many agencies. 

Types of facilities for which information will 
be maintained will include hospitals, nursing 
homes, homes for the aged, rehabilitation facil- 
ities, and diagnostic and treatment centers. 

Information to be included for the facihties 
will include identification of the facilities, type 
of ownership, type of service, accreditations and 
approvals, services offered in the facilities, 
capacity of the facility, utilization of facility, 
summary information on patients receiving 
services, financial information, and employee 
information. 

CONCLUSION 

The Federal-State-Local Health Statistics 
Project gives the Tennessee Depatrment of Pub- 
lic Health the opportunity to increase its 
capacity for collection, processing and analysis 
of statistical information. It is anticipated that 
information obtained through the project and 
other statistical data maintained in the depart- 
ment will enable it to better understand the 
health needs of the people of Tennessee, and 
the resources available to meet its needs. 
Through this understanding, the department will 
be able to plan for its own services and to 
give guidance and information to other agencies 
responsible for meeting the health service 
needs of Tennessee. 


FAMILY PHYSICIANS, INTERNISTS. GEN- 
ERAL PRACTITIONERS. ORTHOPEDIC 
SURGEONS, and OB-GYN needed for 
various connmunities throughout Tennessee. 
AH opportunities are located In towns with 
a modern, fully-equipped, JCAH approved 
hospital. Contact: E. J. Ryan, Jr., Director- 
Medical Relations, Hospital Corporation 
of America, P.O. Box 550, Nashville, Ten- 
nessee 37203. 


Elegant Two Bedroom, Two Bath 
A partment on one of the three lead- 
ing shelling beaches in the world. 
Large screen porch overlooking the 
Gulf of Mexico. Golf and Wildlife 
Sanctuary nearby. Minimum rental 
2 weeks. 

RALPH CALL 
Dept. 15 A 
Sunset South 
Sanibel, Florida 33957 


158 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


A New 

Dosage Form: 



labSets soo mg 

Mlintezol 

THIABENDAZOLE 1 MSO) 



>0 easy to take 
everyone in the family 
:an keep to the 
'egimen you prescribe 


riclude: fever, facial flush, chills, conjunctival injection, 
ngioedema, anaphylaxis, skin rashes, erythema multiforme 
including Stevens-Johnson syndrome), and lymphadenopathy. 
lupplied: Chewable tablets, containing 500 mg thiabendazole, 
n boxes of 36, strip packaged, individually foil wrapped; 
Suspension, containing 500 mg thiabendazole per 5 cc, in 
)ottles of 120 cc. 



MINTEZOL® (Thiabendazole, MSD) has demonstrated effectiveness 
against a broad spectrum of nematode infections. Dosages are 
weight related. For your convenience, the information in the 
weight-dose chart below is included in the full prescribing 
information and in the 1973 edition of PDR. 

The recommended maximum daily dose of MINTEZOL is 3 g 
(6 tablets). 

MINTEZOL should be given after meals if possible. Dietary restric- 
tion, complementary medications, and cleansing enemas are 
not needed. 

The usual dosage schedule for all conditions is two doses per day. 
The size of the dose is determined by the patient’s weight. 


Weight-dose chart: 


WEIGHT 

(lb) 

EACH DOSE 

(g) 

TABLETS 

25 

0.25 

1/2 

50 

0.5 

1 

75 

0.75 

11/2 

100 

1.0 

2 

125 

1.25 

21/2 

150 
& over 

1.5 

3 


The regimen for each indication follows: 


INDICATION 

REGIMEN 

COMMENTS 

Pinworm 

disease 

Two doses per day 
for 1 day. Repeat in 
7 days. 

This regimen is 
designed to reduce 
the risk of rein- 
fection. 

If this is not practical, give 
2 doses per day for 2 
successive days. 

Threadworm,* 
large round- 
worm,* 
hookworm,* 
and 

whipworm* 

disease 

Two doses per day 
for 2 successive 
days. 

A single dose of 20 mg/lb or 
50 mg/kg may be employed 
as an alternative schedule, 
but a higher incidence of side 
effects should be expected. 

Creeping 

eruption 

Two doses per day 
for 2 successive 
days. 

If active lesions are still 
present 2 days after comple- 
tion of therapy, a second 
course is recommended. 

Symptoms of 
trichinosis* 
during the 
invasive phase 
of the disease 

Two doses per day 
for 2 to 4 successive 
days according to 
the response of the 
patient. 

The optimal dosage for the 
treatment of trichinosis has 
not been established. 


^Clinical experience with thiabendazole for treatment of each of these 
conditions in children weighing less than 30 lb has been limited. 


~or more detailed information, consult your MSD representa- 
ive or see full prescribing information. Merck Sharp & 
lohme. Division of Merck & Co., Inc., West Point, Pa. 19486 


Tm 



/pecicil 

item 







The Emerging Specialty of the 
Emergency Department Physician 

WILLIAM T. HAECK, M.D.* 

The emergency physician is a unique entity 
in American Medicine, He was created by pub- 
lic demand. During the 50’s and 60’s increasing 
public mobility, decreasing availability of 
family physicians, and increasing demands of 
the consumer for immediate care led many 
individuals to begin to seek care in emergency 
departments. Visits to emergency departments 
over a 10 year period rose by 300% in some 
places. 

The hospital and the medical staff of the 
hospital share a joint responsibility to treat any 
patient who arrives at the hospital emergency 
department seeking care. The increasing visit 
load in the emergency department increased the 
work load of already busy hospital medical 
staffs. Many staff members also began to feel 
uneasy about being responsible for complicated 
cases they might not have seen or treated since 
the time they started specializing. 

Hospitals and their medical staffs developed 
two generally accepted plans to meet their obli- 
gation to treat emergency patients and to free 
the medical staff to meet ail their other obliga- 
tions. The plans were named for the cities and 
hospitals where they first evolved. 

The Pontiac Plan ensures that there will be 
a physician on duty in the emergency depart- 
ment 24 hours a day. This physician and his 
partners (sometimes as many as 40 or 50) 
maintain their medical practices and agree to 
be present in the emergency department when 
assigned there by the group leader. 

The Alexandria Plan is a further refinement. 


* Project Director, Emergency Medical Services 
Section, Division of Health, State of Florida. 


It also guarantees the presence of a physician (s) 
in the department 24 hours daily. In this plan, 
the physicians in the department limit their 
practice to emergency medicine and their entire 
medical practice is limited to the emergency 
department. 

Many physicians are now making careers of 
emergency medicine. They have obtained 
special training to give them expertise in 
resuscitation, wound care, correction of shock, 
acute heart problems and many acute and com- 
mon problems of every day medical practice. 
Their practices involve stabilization of acute 
problems and initial treatment of non-life- 
threatening problems and referral of the patient 
for definitive care. In many instances, the 
emergency department is now the point where 
patients enter the health care system. 

Many emergency physicians are serving their 
communities by actively becoming involved in 
stimulating their communities to upgrade and 
improve the total emergency medical services 
system in the community. They are often in 
the battle lines fighting for improved ambulance 
services. Many are out in the community teach- 
ing the principles of good first aid and cardio- 
pulmonary resuscitation. They are involved in 
training ambulance attendants and are involved 
in the struggle to bring local, state and federal 
laws up to date to legislate the improved EMS 
systems this country needs. 

The emergency physicians have organized to 
form the American College of Emergency 
Physicians. It now has over 3,000 members. 
University Emergency Department Physicians 
have organized the University Association for 
Emergency Medical Services. Both groups are 
fighting for better emergency care for the Ameri- 
can public through better training for emergency 
physicians, better quality emergency depart- 
ments and better community emergency medical 
care systems. 

Emergency Medicine Today, Vol, 1, No. 9 

John M. Howard, M.D., Ed. 

AMA Commission on Emergency Medical 
Services 



Dollars Today— 

— Doctors Tomorrow 

American Medical Association 
Education and Research Foundation 

535 North Dearborn Street, Chicago 10, Illinois 



166 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



Encounter in Clinical Practice 

Control of primary bacterial offenders 


Antibacterial Gantanol® (sulfamethoxazole) 
controls susceptible strains of E. coli and other 
gram-negative and gram-positive organisms 


often implicated in acute nonobstructed pyelo- 
nephritis and cystitis. 


Prompt antibacterial blood and urine levels 


In from 2 to 3 hours after the initial 2-Gm 
adult dose, antibacterial levels are present in 


both the blood and urine. 


B.I.D./T.I.D. dosage for around-the-clock coverage 


Subsequent 1-Gm doses provide up to 12 
hours of antibacterial coverage. More severe 
u.t.i. may require a q. 8 h. dosage regimen. Either 
schedule provides coverage during the waking 


and sleeping hours— especially important during 
hours of sleep when normal urinary retention 
tends to favor bacterial proliferation. 


Also effective in nonobstructed chronic and recurrent u.t.i. 


It is not uncommon for the elderly and the 
debilitated to develop chronic and/or recurrent 
nonobstructed urinary tract infections such as 
pyelonephritis and cystitis. Such cases often re- 


spond satisfactorily to Gantanol. The increasing 
frequency of resistant organisms is a limitation of 
usefulness of antibacterial agents including sul- 
fonamides,especially in chron ic or recurrent u.t.i. 


Your Option; Tablets or Suspension 


Either dosage form — the Tablets or the 
pleasant-tasting, cherry-flavored Suspension — 
can provide the dependable antibacterial activity 
necessary to control susceptible nonobstructed 
cystitis and pyelonephritis. Symptomatic im- 
provement may usually be expected in 24 to 48 
hours. The usual precautions with sulfonamide 


therapy should be observed, including adequate 
fluid intake. Gantanol (sulfamethoxazole) is gen- 
erally well tolerated with relative freedom from 
complications; the most common side effects 
are nausea, vomiting and diarrhea. Frequent 
c.b.c.’s and urinalyses with microscopic exam- 
ination are recommended. 


In nonobstructed cystitis tl f H II ol 

and pyelonephritis due to ^ fz ^ i \ 

susceptible organisms (sulfamethoxazolc) 

Basic Therapy 




: plastic anemia, thrombocytopenia, leukopenia, hemolytic ane- 
,iia, purpura, hypoprothrombinemia and methemoglobinemia); 
ihllergic reactions (erythema multiforme, skin eruptions, epider- 
[mal necrolysis, urticaria, serum sickness, pruritus, exfoliative 
llermatitis, anaphylactoid reactions, periorbital edema, conjunc- 
hval and scleral injection, photosensitization, arthralgia and 
ifillergic myocarditis); gastrointestinal reactions (nausea, emesis, 
bdominal pains, hepatitis, diarrhea, anorexia, pancreatitis and 
tomatitis); CNS reactions (headache, peripheral neuritis, men- 
tal depression, convulsions, ataxia, hallucinations, tinnitus, ver- 
;igo and insomnia); miscellaneous reactions (drug fever, chills, 
oxic nephrosis with oliguria and anuria, periarteritis nodosa and 
. -E. phenomenon). Due to certain chemical similarities with 
".ome goitrogens, diuretics (acetazolamide, thiazides) and oral 
lypoglycemic agents, sulfonamides have caused rare instances 
)f goiter production, diuresis and hypoglycemia as well as thy- 


roid malignancies in rats following long-term administration. 
Cross-sensitivity with these agents may exist. 

Dosage: Systemic sulfonamides are contraindicated in in- 
fants under 2 months of age (except adjunctively with pyrimeth- 
amine in congenital toxoplasmosis). 

Usual adult dosage: 2 Gm (4 tabs or teasp.) initially, then 
1 Gm b.i.d. or t.i.d. depending on severity of infection. 

Usual child’s dosage: 0.5 Gm (1 tab or teasp.)/ 20 lbs of 
body weight initially, then 0.25 Gm/20 lbs b.i.d. Maximum dose 
should not exceed 75 mg/ kg/ 24 hrs. 

Supplied: Tablets, 0.5 Gm sulfamethoxazole; Suspension, 
0.5 Gm sulfamethoxazole/teaspoonful. 


Roche Laboratories 

Division of Hoffmann-La Roche Inc. 

Nutley. NJ. 07110 


ROCHE 


Answers to the Cooper Quiz 
(from pages 130-131) 

THE NEW ENGLAND JOURNAL OF MEDICINE 
August 3, 1972 

1. (b). “Marihuana smoking by subjects without 
previous experience causes an increase in limb 
blood flow concomitantly with the rise in pulse 
rate. These responses are still evoked after ad- 
ministration of atropine but not after pretreatment 
with propranolol, a beta-adrenergic blocker. The 
tachycardias of atropine and of epinephrine are 
potentiated by marihuana. These findings suggest 
that the increase in pulse rate and peripheral 
blood flow induced by cannabis involves beta- 
adrenergic vascular mechanisms, and counsel cau- 
tion in the administration of vasoactive drugs and 
anesthetics for those who may have been smoking 
marihuana.” (p. 209 — Abstract) 

2. True. “Our findings have several clinical implica- 
tions. The age group most frequently involved 
in road traffic accidents is also the one that most 
commonly smokes marihuana. A persistently high 
cardiac rate in a patient in an accident, not ade- 
quately explained by the clinical situation, might 
be related to cannabis smoked before the accident. 
With hind-sight, this hypothesis may explain cir- 
culatory disturbance, in a number of accident 
cases that, at the time, we could not explain. On 
subsequent questioning, some of these patients ad- 
mitted to smoking marihuana shortly before the 
accident. Premedication with atropine or local 
anesthetic infiltrations containing epinephrine in 
such patients could enhance and prolong this 
tachycardia for a dangerously long period.” (p. 
212 ) 

3. True. “During acute infections resulting in de- 
pression of bone-marrow function, the G-6-PD 
defect might become fully expressed even in 
a patient with sickle-cell anemia. Thus, these 
patients are most likely to receive hemolysis- 
inducing drugs at the time when they are most 
vulnerable to harm by them, Smits et al, re- 
cently reported seven cases of hemolytic crises 
in patients with sickle-cell anemia, all of which 
appeared to be caused by infections or drugs 
triggering hemolysis in G-6-PD-deficient indi- 
viduals. 

“The importance of diagnosing G-6-PD de- 
ficiency in patients with sickle-cell anemia cannot 
be overemphasized.” (p. 215) 

4. False. “It was noteworthy that there was less 
suppression of weight gain for the children on 
methylphenidate than for those on dextroamphet- 
amine. If, as has been suggested by the results 
of Conners, these two drugs are equally efective, 
methylphenidate should be the preferred medi- 
cation. The inverse relation between weight gain 
and methylphenidate dose, however, suggests that 
for the higher dose range, methylphenidate and 


dextroamphetamine have equivalent effects on the 
suppression of weight gain. 

“The second set of data for nine children 
continuously on medication for two or more 
years indicates that the stimulant-induced sup- 
pression of weight gain persists during con- 
tinued use of medication. There appears to be 
no tolerance to this suppression of weight gain, 
although it is still likely that tolerance develops 
to the initial weight loss that many children evi- 
dence after initiation of stimulant medication. 

“The effect of long-term ingestion of stimulant 
drugs on growth in height is more variable than 
its effect on weight change. It is alarming, how- 
ever, to note that precentile height changes cor- 
related significantly with percentile weight vari- 
ations and that percentile height for children 
continuously on stimulant drugs showed a sig- 
nificant decline as compared to that for hyper- 
active children not on medication. Nonetheless, 
because the height percentile changes in the 
experimental group were not significantly changed 
from their base-line levels, the effect of stimulant 
drugs on height remains to be clearly demon- 
strated.” (p. 219) 

5. True. “Immunosuppressive therapy has had a 
dramatic influence on the field of organ trans- 
planation, and today, a dozen years after the 
discovery of the immunosuppressive properties of 
the antipurines, the transplantation of kidneys is 
an accepted and widely practiced form of treat- 
ment. By contrast, immunosuppressive agents 
have thus far failed to revolutionize the treat- 
ment of immunologic diseases. Drugs of this 
type are used in immunologic disorders with the 
expectation that they will inhibit the production 
of pathogenetic antibodies or suppress the inflam- 
matory responses provoked by antigen-antibody 
reactions. But since the etiology and pathogenesis 
of most of these diseases are in fact unknown, 
it is not surprising that such a restricted thera- 
peutic approach is not a panacea,” (p. 221) 

6. (a) “Despite their increasing prevalence, rela- 
tively little is known about the role of im- 
munologic protective mechanisms operative 
against gram-negative infections in man. Al- 
though type-specific antibodies are of paramount 
importance in protection against streptococcal 
and pneumococcal infections, they appear to be 
less effective in protecting against infections 
from enteric gram-negative bacilli. Most people 
possess so-called ‘natural antibodies’ to gram- 
negative bacilli, but these do not appear to pro- 
tect against such infections. Human pyelonephritis 
is another infection in which type-specific anti- 
body to enterobacteria appears to have little pro- 
tective effect. Both persistence of infection in the 
kidney and acquisition of new infecitons have 
been shown to occur despite high titers of 0 spe- 
cific antibody to the infecting organism.” (p. 265) 

7. False. “Well recognized side effects of all the 


170 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


currently employed immunosuppressive drugs 
include myelotoxicity, secondary infections and 
gastrointestinal disturbances. There is no evi- 
dence that the induction of leukopenia is required 
for a beneficial effect from cytotoxic drugs. Our 
own practice is to avoid leukopenia by adjusting 
the dose of drug whenever required. The severity 
of adverse effects of cytotoxic agents is often 
dose-related, and compounded by pre-existing 
impared renal or liver function. Methotrexate 
and 6-mercaptopurine are noteworthy in this re- 
gard, and they should be administered with 
extreme caution to any patient with impaired 
liver or kidney function.” (p. 248) 

8. False. “Recent reviews of legal abortion have 
emphasized the point that termination of preg- 
nancy under supervised conditions, although rela- 
tively safe, is not without risk. Bleeding, lacera- 
tion of the cervix, uterine perforation, infection 
and thromboembolism are well known compli- 
cations. We have recently seen acute defibrino- 
genation with generalized hemorrhage develop 
in a patient after the intra-amniotic injection of 
hypertonic saline (20 per cent sodium chloride), 
and Halbert et al. have reported another case. 
This complication, which is not widely recog- 
nized, prompted an examination of the changes 
in maternal coagulation factors in a series of 
patients undergoing abortion by this method.” 
(p. 321) 

9. (b) “Heparin is considered to be the drug of 
choice for the management of patients with recent 
venous thromboembolism. In the only reported 
controlled study, Barritt and Jordan demonstrated 
that heparin followed by oral anticoagulants pro- 
duced a striking and statistically significant re- 
duction of death and recurrence in patients with 
pulmonary embolism. Nevertheless, the frequency 
of death, recurrent embolism, and bleeding during 
treatment has varied greatly in the many reports 
of heparin treatment of patients with venous 
tromboembolism. In general death and recurrence 
have been least frequent when heparin was given 
intravenously, in a standard high dosage, or in 
doses sufficient to prolong the results of in vitro 
coagulation tests to within a defined therapeutic 
range.” (p. 324) 

10. (b) “The use of a defined therapeutic range to 
adjust herparin treatment is based on the as- 
sumption that complications during treatment — 
namely recurrent thrombosis, embolism, and 
bleeding — are less likely to occur when the 
coagulation-test results are within this range. 
Although animal studies have provided some 
support for this supposition, it has not been 
tested clinically, and it is currently uncertain 
whether monitoring the dose of heparin offers 
any advantage over a standard dose regimen.” 
(p. 324) 

11. True. “The results of this study suggest that 
recurrence of venous thromboembolism during 


heparin treatment is rare if the heparin dose is 
adjusted to prolong the APTT to greater than IV 2 
times control levels at all times. 

“In only five patients (3 per cent) did clinical 
recurrence of venous thromboembolism develop, 
and there were no deaths from pulmonary em- 
bolism during heparin treatment. Before recur- 
rence all had a mean APTT of less than the de- 
fined therapeutic range, and the APTT remained 
below this range for longer periods than in patients 
without recurrence. This was so despite the fact 
that patients with recurrence were treated with 
similar doses of heparin before recurrence as 
patients without recurrence, and suggests that 
patients with venous thromboembolism should be 
given enough heparin to prolong the APTT to 
within the therapeutic range, irrespective of the 
amount of heparin required to obtain that result.” 
(p. 326) 

12. True. “Slowing of heart rate to 60 or fewer beats 
per minute not only may reduce the cardiac out- 
put but also may lead to ventricular irritability. 
Both these complications are particularly unde- 
sirable in patients under treatment in intensive- 
coronary-care units. Consequently, under such 
circumstances it has become customary to ac- 
celerate the heart rate by the intravenous admin- 
istration of atropine. The appearance of ventric- 
ular fibrillation in two patients and short bursts of 
repetitive ventricular firing in a third patient after 
intravenous administration of atropine in the space 
of three months indicates that the use of this drug 
may not be completely without risk.” (p. 336) 

Aug. 24, 1972 

13. (b). “The interaction of drugs, antibodies, and 
platelets to produce thrombocytopenia is well 
known. However, an antigenic role for a drug 
metabolite in this disorder has not been recog- 
nized. We recently had the opportunity to study 
a patient with acute drug-induced thrombocy- 
topenia in whom a drug metabolite rather than 
the drug itself proved to be the responsible anti- 
gen. The patient, a 22-year-old man, was ad- 
mitted to the hospital one day after the onset of 
gross purpura and was found to have a platelet 
count of 4000. The bone-marrow aspirate con- 
tained increased numbers of megakaryocytes. 
There were no other clinical or hematologic ab- 
normalities. 

Aug. 31, 1972 

14. True. “Any increase in the maintenance dose of 
salicylate will result in a more than proportional 
rise in the plateau level of salicylate in the body; 
this level is reached more slowly by repeated 
administration of large daily doses (irrespective of 
dosing interval) than with smaller doses. These 
characteristics must be taken into consideration in 
the design of dosage regimens and in the monitor- 
ing of patients. The maximum response from the 
usual therapeutic regimen (4 g daily or more) of 
salicylate or aspirin (which is hydrolyzed rapidly 


FEBRUARY, 1973 


171 


in the body to salicylate) cannot be expected to 
occur in less than one week, and plasma salicylate 
concentrations are likely to increase up to that 
time. 

“The data presented here explain recently re- 
ported clinical observations that a 50 per cent 
increase in the daily dose of aspirin (from 65 to 
100 mg per kilogram) produced about a 300 per 
cent rise in the concentration of salicylate in the 
serum.” (p. 431) 

15. True. “An increased frequency of chromosomal 
abnormalities has been noted in fetuses from 
spontaneous abortions. Because some chromosomal 
deviations are associated with dermatoglyphic ab- 
normalities, this study was undertaken to deter- 
mine if any specific dermatoglyphic pattern was 
more prevalent in women with increased fetal 
wastage. The dermatoglyphic findings in these 
women were compared to the fingerprints of 
women to have had no reproductive failure. 

“This study shows an association between the 
presence of a fingerprint pattern of 10 whorls and 
fetal wastage. No women in the control group 
who had two or more normal pregnancies de- 
monstrated a 10-whorl pattern.” (p. 451) 

JAMA 

August 7, 1972 

16. True. “The incubation period is the only reliable 
clinical criterion for distinguishing between short- 
incubation infectious hepatitis (IH) and long- 
incubation serum hepatitis (SH) infections with 
the hepatitis virus. Unfortunately, except in 
epidemic infections or in those that follow par- 
enteral injection of infected materials, it is dif- 
ficult, if not impossible, to establish the source of 
infection and date of exposure. Moreover, even 
when the source and mode of infection can be 
identified, distinction between IH and SH infec- 
tions still requires an accurate estimate of the 
incubation period, since both can be transmitted 
by either the oral or parenteral route.” (p. 571) 

17. True. “The date presented confirm previous re- 
ports that, early in the course of the disease, serum 
IgM concentration is significantly higher in 
patients with short-incubation (IH) than in those 
with long-incubation (SH) infections. However, 
it is apparent from our observations that the over- 
lap of values in the two groups was too great 
to permit use of the IgM level as a criterion for 
distinguishing between these two types of infec- 
tion.” (p. 575) 

18. False. “In accord with previous reports, we ob- 
served that, during the acute phase of the disease, 
thymol turbidity levels were significantly higher 
in patients with IH than in those with SH infec- 
tions. Although the separation between the 
values in the two groups was greater than in the 
case of serum IgM concentration, there was suf- 
ficient overlap to render the thymol turbidity level 
unsatisfactory as a criterion for distinguishing 
between IH and SH infections.” (p. 575) 


19. False. “In recent years, public concern over the 
use of certain hallucinogenic agents has ob- 
scured the fact that commonly used belladonna 
alkaloids also produce mind-altering effects. A 
related preparation is stramonium which had been 
used for many years to relieve asthma. It is 
available as cigarettes, pipe mixture or powder to 
be burned like incense, and the asthmatic patient 
uses it by inhaling the smoke. 

“A typical asthma preparation contains 50% 
stramonium, 25% potassium nitrate to facillitate 
burning, belladonna, grindelia, or tobacco to make 
the desired bulk, along with trace amounts of 
flavoring agents. The alkaloids of stramonium 
are the same as those of belladonna: scopolamine 
and atropine in varying proportions depending on 
species and conditions of cultivation, harvesting, 
and storage. The mixture is adjusted to an alkaloid 
content of 0.3%, the equivalent of 1.25 mg of 
atropine per unit dosage, eg, per cigarette, pipe- 
ful, etc. About 1/100 of the available alkaloid 
is absorbed systemically when the product is used 
as directed. 

August 14, 1972 

20. True. “Findings from a 16-year follow-up study 
of 5,209 Framingham adults indicate that blood 
pressure, serum cholesterol, cigarette smoking, 
electrocardiographic evidence of left ventricular 
hypertrophy, and glucose intolerance are precur- 
sors common to all three major atherosclerotic 
events — atherosclerotic brain infraction (ABI), 
coronary heart disease (CHD), and intermittent 
claudication (IC). The dominant factor predis- 
posing to ABI is high blood pressure. None is 
clearly dominant for CHD. Glucose intolerance 
is only weakly related to this disease while cigar- 
ette smoking is related weakly (if at all) to angina 
pectoris. All five factors play an important role 
in IC. In general, relationships appear to be as 
strong for women as men. When all five variables 
are considered jointly, they have a closer relation- 
ship with ABI and IC than with CHD, and equally 
strong relationships in every age group between 
45 and 74 years of age.” (p. 661) 

21. (b). “Kennedy and Simpson compared aerosols 
containing 200^g of isoproterenol and 400 ^g 
of albuterol in six normal volunteers and found 
no change in heart rate or blood pressure after 
albuterol, whereas isoproterenol produced sig- 
nificant increases in pulse rate and systolic blood 
pressure and a fall in diastolic pressure. 

“This study was designed primarily to evaluate 
duration of bronchodilator effect of albuterol rather 
than its cardiovascular effects. 

“The mechanism for the longer duration of 
albuterol is intriguing. ... It is of interest that 
tritiated albuterol given by aerosol appears much 
later in the urine than a comparable dose given 
orally, and it may be that the drug is more slowly 
absorbed from the bronchial tree than from the 
gut.” (p. 685) 


172 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


22. Does not. -The failure to demonstrate significant 
changes in VMA excretion with the different diets 
suggests that dietary restriction of these foods is 
not necessary prior to determining urinary VMA 
excretion. This will be a great relief for dieticians, 
physicians, and the many hypertensive patients in 
whom a VMA collection is a routine screening 
test for pheochromocytoma.” (p. 705) 

23. False. “Extended hemodialysis in small children 
has not been an accepted therapeutic modality 
because of a lack of information regarding tech- 
nical feasibility, cannula function, growth, and 
psychosocial adaptation of patient and family. 
This report has attempted to clarify these ques- 
tions. 

“Technical problems encountered during di- 
alysis of these children were few in number and 
easily overcome. Modification of commercially 
available equipment to permit a smaller volume 
of the child’s blood to circulate in the dialyzer was 
the only significant technical adjustment required. 
. . . Few difficulties were encountered due to 
cannula malfunction and only eight of 18 children 
required revisions during the period of dialysis. 

“Normal linear growth occurred in five chil- 
dren on dialysis. An additional child grew at 60% 
of the normal rate. Two children failed to grow. 
Wfiether or not adequate caloric intake during the 
period of dialysis is the critical factor affecting 
growth remains to be substantiated. However, our 
data on three children confirm the findings of 
Simmons et al that adequate caloric intake is 
associated with normal linear growth in children 
on dialysis. 

“The smaller younger children and their 
families adapted well to the dialysis program; in 
fact the younger children had less difficulty than 
many adolescent patients.” (p. 873) 

24. False. “To assess the diagnostic value of brain 
scanning in pediatrics, results in 556 children were 
analyzed. Follow-up data were available in 409 
children. Of these, 37% had brain scans done be- 
cause of seizures; other frequent indications were 
motor abnormalities (7.4%), headache (5.0%), 
suspected optic neuritis (4.9%), raised intracranial 
pressure (4.9%), and trauma (4.7%). Fifteen 
percent of the scans were abnormal, most often 
because of tumors of the brain, pituitary fossa, 
brain stem, and cerebellum; subdural collections; 
cerebral abscess; and encephalitis. Three scans 
were false-positive; 12 patients with tumors had 
normal scans. Scans were graded according to 
the extent they changed the prior diagnosis. They 
were found most useful in patients suspected of 
having posterior fossa disease, raised intracranial 
pressure, generalized encephalopathy or metastases, 
and after trauma, and least useful in cases of 
generalized seizures and mental or behavioral 
abnormalities.” (p. 877) 

25. No. “I do not think it is feasible to make a con- 
clusive diagnosis in the absence of histological 


evidence. The term chronic active hepatitis de- 
scribes accurately the clinical picture that often 
accompanies the histological lesion described, but 
in the absence of that histological lesion the diag- 
nosis must be seriously questioned. Certainly the 
diagnosis cannot be established by clinical criteria 
alone. When liver biopsy cannot be performed 
and the clinical situation warrants it, a presump- 
tive diagnosis may be made and therapy instituted. 
The diagnosis should be confirmed by liver biopsy 
at a later date in such cases.” (p. 891) 

Aug. 28, 1972 

26. True. “The chemistry laboratories and the drug 
developers are bringing to the market new sub- 
stances almost daily. It can be expected that there 
will be other ‘quests’ with newer substances as we 
struggle to help the aspiring young athlete learn 
to depend only upon himself for his performance 
and his development. One real problem is that, 
to my knowledge, in all of the literature there is 
no good scientific evidence that any of these sub- 
stances really helps the athletic performance of 
anyone. 

“The combination of amphetamines with barbi- 
turates has also enjoyed a certain amount of 
popularity among some athletes and is often refer- 
red to as a greenie. The combination apparently 
gets the amphetamine titillation to the pleasure 
and ego support centers, but the presence of barbi- 
turates alleviates some of the nervousness and 
shakiness felt as side effects of the amphetamines 
alone. As far as any increased ability or efficiency 
is concerned, the performance is no better and 
in many instances the athlete actually performs 
worse. Subjectively he will tell you he feels his 
performance is better.” (p. 1008) 

27. True. “Like most endurance athletes, marathon 
runners are characterized by their highly devel- 
oped aerobic capacities (VOoUiax) and an ability 
to tolerate high rates of energy expenditure (70% 
to 90% VooUiax) without accumulating blood 
lacate. During marathon competition these men 
must alter their speed to compensate for the detri- 
mental effects of uneven terrain, wind resistance, 
and thermal stress. Such factors add to the cir- 
culatory and metabolic demands of running. Heat 
produced in the active muscles must be transported 
to the body surface via the circulatory system and 
subsequently dissipated to the environment. Since 
the major responsibility of circulation is to trans- 
port nutrients and metabolic wastes, increasing the 
environmental heat stress will overload the circu- 
latory system, thereby reducing performance and 
posing a risk to the runners’ health.” (p. 1024) 

ANNALS OF INTERNAL MEDICINE 
August 1972 

28. True. “A study of the incidence of Hodgkin’s 
disease in Albany County, N.Y., from 1950 
through 1970, showed a period of high incidence 
followed by an apparently reciprocal period, when 
the incidence of the disease was below average. 


FEBRUARY, 1973 


173 



standing 


veins 


made Man safer 
from attack but 
increased blood 
pressure in 
hemorrhoidal 


Precaution 

Prolonged or excessive 
use of Anusol-HC might 
produce systemic 
corticosteroid effects. 
Symptomatic relief should 
not delay definitive 
diagnosis or treatment. 
Dosage and Administration 
Anusol-HC: One suppository 
in the morning and one at 
bedtime for 3 to 6 days 
or until the inflammation 
subsides. 

Regular Anusol: one 
suppository in the morning, 
one at bedtime, and one 
immediately following each 
evacuation. 


to help ease 
acute symptoms of 
hemorrhoids 


Anusol’HC 


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The increased incidence closely paralleled tempo- 
rally the occurrence of cases in a specific group of 
students, their friends, and household relatives. 
Thirty-four lymphoma cases, of which 31 were 
Hodgkin’s disease, have been interlinked to date. 
These observations and the occurrence of similar 
Hodgkin’s disease groupings in two different areas 
suggest that the pattern of disease occurrence was 
similar to that of an infectious disease.” (p. 169) 

29. Was. “Thus, the available evidence suggests that 
Hodgkin’s disease was transmitted either directly 
from case-to-case or through some health carrier. 
The existence of an asymptomatic carrier state of 
subclinical infection is recognized in many com- 
municable diseases. It would seem likely that 
transmission of the hypothesized infectious agent (s) 
occur through direct contact, the oral-respiratory, 
or gastro-intestinal routes, or both, and that an 
incubation period of years precedes the clinical 
manifestations. Moreover, it would appear that 
either some individuals are more infectious than 
others or that other unknown risk factors pro- 
moting transmission vary.” (p. 179) 

30. Increased. “Proof that anemia is caused by iron 
deficiency usually depends on laboratory tests. 
Morphological interpretation of the blood smear 
is difficult, and changes in erythrocyte morphology 
and red cell indexes are often absent in mild iron 
deficiency. Serum iron levels and iron-binding 
capacity are more sensitive indexes of iron defi- 
ciency, but they too often fall within the normal 
range when the anemia is mild. Examination of 
the bone marrow aspirate for stainable iron has 
been regarded as one of the most sensitive and 
reliable diagnostic methods for detecting iron 
deficiency. This view is reasonable, but the tech- 
nique has several limitations, and a more practical 
but reliable and sensitive substitute is needed. 

“Cobalt absorption is increased in iron defi- 
ciency, and the absorbed cobalt is excreted in the 
urine. Recently, a test based on the urinary 
excretion of an oral dose of ^'^Co has been pro- 
posed as a method for detecting iron deficiency. 
We describe a simplification of the technique, with 
a 6-hour rather than a 24-hour urine collection, 
and the use of the test for the investigation of 
anemia and the assessment of body iron balance.” 
(p. 181) 

31. False. “In our study the cobalt test clearly dis- 

tinguished between patients with iron deficiency 
anemia and patients with anemia due to causes 
other than iron lack: patients with the former 

excreted more than 12% of the dose, whereas 
those with the latter excreted less than 11%. Hence 
the finding of a value of 11% or less in a patient 
with anemia suggests that the primary cause of the 
anemia is not iron deficiency, and a search for 
other causes is warranted. A value greater than 
11% in an anemic subject suggests that the anemia 
is caused by iron deficiency.” (p. 185) 


32. False. “The small amounts of cobalt used in the 
test have led to no untoward effects. The radio- 
activity that is administered is similar to that used 
in the Schilling test for vitamin absorption, 
and the radiation exposure is negligible.” (p. 187) 

33. False. “Fanner’s lung may be as old as society 
and has been more intensively studied than the 
other less well documented examples of extrinsic 
allergic pneumonia. The definition has been given 
as ‘pulmonary disease due to the inhalation of the 
dust of moldy hay or other vegetable produce 
characterized by symptoms and signs attributable 
to a reaction in the peripheral part of the broncho- 
pulmonary system and giving rise to a defect in 
gas exchange.’ This definition of farmer’s lung 
clearly separates the condition from that of 
asthma, ‘an intermittent increase in airways resis- 
tance reversible spontaneously or by therapy,’ yet 
is broad enough to allow the inclusion of bagasse 
worker’s lung or any similar response. The disease 
results from the repeated exposure to the dust of 
moldy hay (oats, corn, barley, beet pulp) but not 
apparently to the dust of moldy soybean or pea- 
nuts. Only about 50 per cent of heavily exposed 
persons are affected.” (p. 132) 

34. True. “After a variable period of exposure to the 
dust of moldy hay, commonly six to ten weeks, 
re-exposure is followed four to six hours later by 
the characteristic Arthus reaction. 

“Thirty-five per cent of cases present with this 
delayed sudden onset of malaise, anorexia, shiver- 
ing, nonproductive cough and shortness of breath. 
Examination reveals fever, tachypnea and possi- 
bly scattered inspiratory rales. After a few days 
the symptoms resolve pending further re-exposure. 

“Forty-nine per cent present with a less typical 
insidious onset of progressive weakness and short- 
ness of breath that may suggest some other inter- 
stitial process. Nine per cent commence with an 
insidious onset, and with repeated re-exposures, 
more typical acute attacks occur. Ten per cent 
give a history of acute or insidious onset, to be 
followed later by attacks of extrinsic nonatopic 
asthma on further exposure. After months or more 
of exposure, the patient may present with a pic- 
ture indistinguishable from that of diffuse inter- 
stitial fibrosis.” (p. 133) 

35. False. “Roentgenologic changes are usually bi- 
lateral but may not be symmetrical. Diffuse in- 
filtrates, varying in size from millet seed (miliary) 
to large coalescent densities may be seen, or alter- 
natively, areas of ‘alveolar’ consolidation and 
atelectasis. Hilar lymphadenopathy is not a 
feature. Resolution may take weeks or months. 
In subacute cases with insidious onset the roent- 
genogram may be normal; in chronic cases, a pic- 
ture may be of diffuse interstitial fibrosis. Only in 
the acute phase does the roentgenogram correlate 
with the clinical state.” (p. 133) 


FEBRUARY, 1973 


175 


Professional Liability Insurance 

(MALPRACTICE) 


Policy and Rates Approved 

by the TENNESSEE MEDICAL ASSOCIATION 

Standard Coverage That SAVES YOU 23% to 27% 

Class I — Physicians doing no surgery. 

Class 2 — Physicians doing minor surgery or assisting in major surgery 
on own patients. 

Class 3 — Surgeons — General Practitioners who perform major surgery 
or assist in major surgery on other than their own patients and 
specialists hereafter indicated: Cardiologists (including cathe- 
terization, but not including cardiac surgery), Ophthalmolo 
gists. Proctologists. 

Class 4 — Surgeons — specialists. Anesthesiologists, Cardiac Surgeons, 
Otolaryngologists — No Plastic Surgery, Surgeons — General 
(Specialists in general surgery). Thoracic Surgeons, Urologists. 
Vascular Surgeons. 

Class 5 — Surgeons — specialists. Neurosurgeons, Obstetricians-Gyne 
cologists. Orthopedists, Otolaryngologists — Plastic Surgery, 
Plastic Surgeons. 



Territory Schedule & Code 


Davidson County 01 

Shelby County 03 

Knox County 04 

Remainder of State 05 



Limits 

Class 1 

Class 2 

Class 3 

Class 4 

Class 5 

Territory 

5/15 

... $ 44.00 

$ 75.00 

$ 1 3 1 .00 

$ 1 74.00 

$218.00 

01,04 

25/75 

... 9 1 .00 

155.00 

271.00 

360.00 

45 1 .00 


50/150. . . . 

... 103.00 

176.00 

307.00 

407.00 

510.00 


100/300. . . 

... 114.00 

194.00 

339.00 

45 1 .00 

565.00 

Territory 

5/15 

. . .$ 43.00 

$ 75.00 

$128.00 

$170.00 

$213.00 

03 

25/75 

. . . 89.00 

155.00 

265.00 

352.00 

441.00 


50/150. . . . 

... 101.00 

1 76.00 

300.00 

398.00 

498.00 


100/300. . . 

... 1 II .00 

194.00 

332.00 

440.00 

552.00 

Territory 

5/15 

. . . $ 42.00 

$ 73.00 

$125.00 

$166.00 

$208.00 

05 

25/75 

. . . 87.00 

151.00 

259.00 

344.00 

431.00 


50/150 . . . 

, . . 98.00 

1 7 1 .00 

293.00 

388.00 

487.00 


100/300. . . 

... 109.00 

189.00 

324.00 

430.00 

539.00 


FAW & SHERROD 
Phone 926-8164 

Johnson City. Tennessee 37602 


INGLE-KNOX INSURANCE AGENCY 
Phone 265-4541 

Chattanooga, Tennessee 37402 


LIPSCOMB & PITTS CO. 

Phone 278-0772 
Memphis, Tennessee 38104 


1. Partnership liability, Increase premium tor each partner by 

20 %. 

2. X-Ray Therapy and Shock Therapy quotations made on 
request. 

3. Premises Liability (bodily injury, property damage and 
medical payments) Minimum premium $12.00. 

Shelby Mutual Insurance Company 

of Shelby, Ohio 

Your policy is backed by Assets over $62,000,000.00 


For information on Hospital Professional Liability and other coverages please contact one of the agents listed. 


176 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 




nalotestin'5 mg tablets 

fluoxymesterone/ Upjohn 

oral hormone replacement with parenteral-like potency 


Halotestin® Tablets — 2, 5 and 10 mg 

(fluoxymesterone Tablets, U.S.P., Upjohn) 

Indications in the male: Primary indication in the 
male is replacement therapy. Prevents the devel- 
opment of atrophic changes m the accessory male 
sex organs following castration: 

1. Primary eunuchoidism and eunuchism. 2. Male 
climacteric symptoms when these are secondary 
to androgen deficiency. 3. Those symptoms of 
panhypopituitarism related to hypogonadism 4. 
Impotence due to androgen deficiency. 5. Delayed 
puberty, provided it has been definitely estab- 
lished as such, and it is not just a familial trait. 

In the female: 1. Prevention of postpartum breast 
manifestations of pain and engorgement. 2. Pal- 
liation of androgen-responsive, advanced, inoper- 
able female breast cancer m women who are more 
than 1. but less than 5 years post-menopausal or 

JA7I-I008R 


who have been proven to have a hormone-de- 
pendent tumor, as shown by previous beneficial 
response to castration. 

Contraindications: Carcinoma of the male breast. 
Carcinoma, known or suspected, of the prostate. 
Cardiac, hepatic or renal decompensation. Hyper- 
calcemia. Liver function impairment. Prepubertal 
males. Pregnancy. 

Warnings: Hypercalcemia may occur in immobil- 
ized patients, and m patients with breast cancer. 
In patients with cancer this may indicate progres- 
sion of bony metastasis. If this occurs the drug 
should be discontinued. Watch female patients 
closely for signs of virilization. Some effects may 
not be reversible. Discontinue if cholestatic hepa- 
titis with jaundice appears or liver tests become 
abnormal. 

Precautions: Patients with cardiac, renal or he- 
patic derangement may retain sodium and water 


thus forming edema. Priapism or excessive sexual 
stimulation, oligospermia, reduced ejaculatory 
volume, hypersensitivity and gynecomastia may 
occur. When any of these effects appear the an- 
drogen should be stopped. 

Adverse Reactions: Acne. Decreased ejaculatory 
volume. Gynecomastia. Edema. Hypersensitivity, 
including skin manifestations and anaphylactoid 
reactions. Priapism. Hypercalcemia (especially in 
immobile patients and those with metastatic breast 
carcinoma). Virilization m females. Cholestatic 
jaundice. 

How Supplied 

2 mg — bottles of 100 scored tablets. 

5 mg — bottles of 50 scored tablets. 

10 mg — bottles of 50 scored tablets. 

For additional product information, see your 
Upjohn representative or consult the package 
circular. meo e-e-s iMAHi 


Upjohn 


The Upjohn Company, Kalamazoo. Michigan 49(X)1 




ioumcil 

OF THE 

TENNESSEE MEDICAL 
ASSOCIATION 

MARCH, 1973 

Vol. 66 No. 3 

Published Monthly By 
Tennessee Medical Association 
Office of Publication, 
112 Louise Avenue 
Nashville, Tenn. 37203 

Second Class Postage Paid at 
Nashville, Tenn. 

TMA OFFICERS 

President 

Wm. T. Satterfield, Sr., M.D. 

1188 Minna Place 
Memphis 38104 
President-Elect 
0. Morse Kochtitzky, M.D. 
2104 West End Ave. 
Nashville 37203 
Chairman, Board of Trustees 
C. Gordon Peerman, Jr., M.D. 
21st & Hayes Medical Bldg. 

Nashville 37203 

EDITORIAL STAFF 

Editor 

John B. Thomison, M.D. 
Managing Editor and 
Business Manager 
Jack E. Ballentine 

TMA EXECUTIVE STAFF 

Executive Director 

Jack E. Ballentine 
Assistant Executive Director 
L. Hadley Williams 
Executive Assistant 
John M. Westenberger 
Executive Assistant 
William V. Wallace 
Executive Assistant 
for Legislation 
John R. Coles 

The Journal of the Tennessee 
Medical Association 
112 Louise Ave. 
Nashville, Tennessee 37203 

Published monthly under the direction of 
the Board of Trustees for and by members 
of The Tennessee Medical Association, a 
nonprofit organization, with a definite 
membership for scientific and educational 

purposes. 

Subscription $9.00 per year to non- 
members; single copy, 75 cents. Payment 
of Tennessee Medical Association 
membership dues includes the subscription 
price of this Journal. 
Devoted to the interests of the medical 
profession of Tennessee. This association 
does not officially endorse opinions 
presented in different papers published 
herein. Copyright, 1973 by the Journal of 
the Tennessee Medical Association. 
Advertisers must conform to policies and 
regulations established by the Board of 
Trustees of the 
Tennessee Medical Association. 


contcAl/ 

SCIENTIFIC SECTION 

215 Lithium Carbonate in the Ambulatory, Chronically Psychotic Patient, 

W. Lewis Neal, M.D. and Kenneth J. Munden, M.D. 

217 Nitrofurantoin Macrocrystals in the Treatment of Simple Cystitis in 
Women, Frank Malone, M.D. 

221 Recognition of Curable Forms of Hypertension, Grant W. Liddle, M.D., 
Ronald D. Brown, M.D., Victoria R. Liddle 

225 Staff Conference 

229 EKG of the Month 

231 Topics in Nuclear Medicine 

233 Laboratory Medicine 

234 From Tennessee Department of Mental Health 
236 Self-Evaluation Quiz 

248 Special Section 

NEWS AND ORGANIZATIONAL SECTION * 

264 Special Item 

266 President’s Page 

267 Editorial 

268 Mail Box 

270 In Memoriam 

271 New Members 

271 Programs and News of Medical Societies 
271 National News 

274 Medical News in Tennessee 

275 Personal News 

276 Announcements 

286 Report of the 1972 Opinion Survey 

305 Placement Service 

306 Index to Advertisers 

Contents listed in CURRENT CONTENTS/CLINICAL PRACTICE 
of The Institute for Scientific Information 


INSTRUCTIONS TO CONTRIBUTORS 

Manuscripts submitted for consideration for publication in the JOURNAL 
OF THE TENNESSEE MEDICAL ASSOCIATION should be addressed to 
the Editor, John B. Thomison, M.D., P.O. Box 70, Nashville, Tennessee 
37202. 

Manuscripts must be typewritten on one side of letterweight paper. 
Either double or triple spacing and wide margins must be provided to 
facilitate editing which will be legible for the printer. The pages should 
be numbered and clipped or stapled together, but they should not be 
placed in a binder. 

Bibliographic references should not exceed twenty in number docu- 
menting key publications. They should appear at the end of the paper. 
The bibliographic references must conform to the style used in the 
American Medical Association publications, as, — Alais, FG: What is Known 
About it, J. Tennessee M. A., 35:132, 1950. 

Illustrations should be numbered and identified with the author’s name. 
The editor will determine the number, if any, of illustrations to be used 
with the Journal assuming the cost of engravings and cuts up to $25. 
Engraving cost for illustrations in excess of $25 will be billed to the 
author. They will not be returned unless specifically requested. 

If reprints are wanted, the desired number should be indicated in the 
letter accompanying the manuscript. No reprints are provided free and 
a reprint cost schedule will be forwarded upon request. 


joumol 

OF THE TENNESSEE MEDICAL ASSOCIATION 

OWNED AND PUBLISHED BY THE ASSOCIATION 

MARCH, 1973 
VOLUME 66, NO. 3 


Lithium Carbonate in the Ambulatory, 

Chronieally Psyehotie Patient 


Currently it is generally agreed that lithium 
carbonate (Li 2 COs) is the drug of choice both 

for the active treatment of the acute mania and 

% 

for the prophylactic treatment of both phases of 
manic-depressive disorder. Additionally, the 
drug is adjudged to be of some benefit in cer- 
tain selected cases of schizophrenia of the 
schizo-alTective variety. At the present time 
responsible medical authorities do not advocate 
the routine utilization of lithium carbonate in 
individuals diagnosed as chronically schizo- 
phrenic. 

With the foregoing in mind, the following is 
written in order to report the quite definite and 
dramatic responses to lithium carbonate of acute 
psychotic processes in six patients diagnosed as 
chronically schizophrenic. The acute psychoses 
were treated entirely on an outpatient basis 
without a single day of hospitalization for any 
of the six patients included in this report. An- 
other group of five acutely psychotic patients 
with past diagnoses of chronic schizophrenia 
were treated with Li 2 CO :3 on an outpatient basis. 
These five patients failed to respond adequately 
to Li 2 C 03 and are not described in this report. 

During a four-month period in early 1972, the 
six patients, each carrying a long-standing diag- 
nosis of schizophrenia (three were diagnosed as 
chronic paranoid schizophrenia, and three as 
chronic undifferentiated schizophrenia) were 
seen in the Outpatient Department for evalua- 
tion of irrational behavior. None of the six 
patients was experiencing his initial episode of 
severe emotional-mental disturbance; all six 
patients had required inpatient care in the past 

*From the Tennessee Psychiatric Hospital and In- 
stitute, Outpatient and Community Services, Memphis, 
Tenn. 


W. LEWIS NEAL, M.D. AND KENNETH J. MUNDEN, M.D. 

for episodes of gross irrationality. Each of the 
six patients had at least one family member who 
was deeply interested in seeing the patient re- 
turn to normalcy and who was living under the 
same roof with the patient. Five of the six 
patients had been hospitalized for emotional- 
mental disturbances four or more times in the 
past. One of the six had been an inpatient only 
once. 

Examination of the old charts disclosed that 
in only one of these six patients was there even 
a passing reference to the possibility of any 
psychotic diagnosis other than paranoid or un- 
differentiated schizophrenia. Additionally, none 
of the six old charts contained any psychological 
tests interpreted to suggest manic-depressive 
disorder or schizo-affective schizophrenia. 

All six patients on separate occasions had 
each been individually evaluated, diagnosed, and 
treated by at least three psychiatrists prior to 
their seeking outpatient assistance in 1972. All 
six had been inpatients in a state psychiatric 
facility in the past, and five of the six had each 
been evaluated by at least one private psychia- 
trist. 

Outpatient control was made possible in 
each case ( 1 ) by placing complete responsibility 
for the administration of the potentially toxic 
drug, lithium carbonate, in the hands of a sup- 
portive and responsible adult family member, in 
whom the patient had some (however slight) 
degree of trust, (2) by administering Mellaril 
(usually 100 mg q.i.d.) usually during the 
first five days of lithium administration, (3) by 
seeking to establish and maintain serum lithium 
levels within a range of 0.50 mEq L to 1.00 
mEq/L, (4) by obtaining blood lithium levels 
weekly, (5) by brief outpatient visits weekly, 


MARCH, 1973 


215 


and (6) by providing in each case for the possi- 
bility of immediate hospitalization of any patient 
in case of the development either of profound 
worsening of the psychotic process or of acute 
lithium toxicity. Neither of these two specific 
complications occurred in the six cases cited 
and, consequently, inpatient care was not neces- 
sary after the initiation of lithium carbonate in 
the Outpatient Department. 

After obtaining baseline studies in each case, 
a member of the patient’s family was instructed 
in the proper administration of lithium carbon- 
ate. On the first day of therapy, the family 
member was to give the patient one 300 mg 
capsule of lithium carbonate b.i.d. (Li2C03 
was stated in b.i.d. dosage in order to mini- 
mize the possibility of nausea.) On the follow- 
ing four days the patient was to receive Li2C03 
300 mg q.i.d., to be taken with meals or 
with milk and soda crackers whenever practi- 
cable. The soda crackers provide the patient with 
some of the extra sodium he should have while 
taking lithium carbonate, and the milk serves to 
reduce the hypertonicity of the gastric juices that 
is the consequence of lithium carbonate ingestion 
and the occasional cause of nausea. 

During these first five days, the family mem- 
ber was to exercise his or her own discretion in 
the administration of Mellaril to control the 
patient’s psychotic behavior. Mellaril was gen- 
erally to be administered 100 mg q.i.d.; how- 
ever, the family member was at liberty to ad- 
minister a total daily dosage of 200 mg to 800 
mg. 

On the sixth and seventh days, Mellaril was 
to be discontinued entirely and Li2C03 dosage 
was to be reduced to 300 mg t.i.d. On the 
eighth day the patient was to return to the Out- 
patient Department accompanied by the family 
member. The patient was to fast for twelve 
hours prior to venipuncture on this eighth day. 

At this visit, it was possible for the out- 
patient physician to interview and examine the 
patient to observe the effects of a week of 
lithium therapy without the masking effect of 
Mellaril. If the patient demonstrated marked 
improvement, the maintenance dosage of lithium 
carbonate was determined on the basis of the 
serum level of lithium. Even when the patient 
had improved dramatically, Mellaril tablets were 
made available in case of relapse. If, on the 
other hand, psychotic symptoms persisted un- 
relieved after one week, Li2C03 and Mellaril 


were again administered in combination. 

Editor’s Note: Protocols of the six patients, 
omitted here, may be obtained by those inter- 
ested by writing the authors. 

Eive of the six patients demonstrated dramat- 
ic improvement after one week, at which time 
Mellaril was withdrawn completely v/hile lithium 
carbonate was continued on a maintenance 
basis. Blood levels of lithium were maintained 
between 0.5 and 1.0 mEq/T. In the sixth 
patient, symptoms of disorientation, decreased 
need for sleep, and marked elevation of mood 
persisted for four weeks after initiation of lithium 
carbonate, at which time the psychotic episode 
terminated suddenly and dramatically. Response 
in this patient was related to a sharp increase 
in the daily dosage of lithium carbonate. 

All six patients exhibited complete resolution 
of their acute psychotic process, and, at the time 
of this writing, have remained free of recurrence 
of psychotic symptoms. Five of the six patients 
are being maintained on lithium carbonate as a 
prophylactic measure. In one it was necessary 
to discontinue maintenance Li2C03 when a mild 
degree of polyuria (with nocturia) developed 
after five months of therapy. The polyuria 
cleared completely within a few days after 
stopping Li2COs. Two of the six patients are 
working full-time, one is working part-time, two 
are functioning effectively as housewives, and 
one is attending school. 

Although each of the six patients exhibited 
thoroughgoing disorganization of thought during 
the initial outpatient interview, all were con- 
trolled solely on an outpatient basis to the point 
of total dissolution of the acute psychotic pro- 
cess. 

CONCLUSION 

Within the limitations of our present knowl- 
edge, it is impossible to determine with cer- 
tainty the final interpretation of the foregoing 
reported facts. It is indeed certain that much 
has yet to be learned about the precise indica- 
tions for the utilization of lithium carbonate. It 
is additionally certain that the six cases cited 
above demonstrate conclusively that even the 
repeated diagnosis of chronic schizophrenia is 
not an absolute contra-indication for the utiliza- 
tion of lithium carbonate in a patient presenting 
with acute psychosis. This study emphasizes the 
va^ue of the drug in clinical practice in ambula- 
tory patients, and its potential effectiveness in 
those previously considered unresponsive. 


216 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Nitrofurantoin Macrocrystals in the 
Treatment of Simple Cystitis in Women 

FRANK MALONE, M.D. 


Although not as dramatic in treatment re- 
quirements as most other urological problems, 
urinary tract infections are frequent and im- 
portant illnesses in many clinical practices. 
Selection of the proper single antibacterial drug, 
with low toxicity, is often quite difficult. The 
matter of resistant bacteria is becoming an in- 
creasing problem since the introduction of anti- 
bacterial agents, adding another element to the 
physician’s challenge. This clinical study was 
done to support the proposition that the macro- 
crystalline form of nitrofurantoin (Macrodantin 
capsules, Eaton Laboratories) meets most of 
the criteria for single drug therapy in the treat- 
ment of simple cystitis in women. 

The Macrodantin capsule was developed as 
a direct response to the need for an anti-infec- 
tious agent with the specific activity of micro- 
crystalline nitrofurantoin (Furadantin, Eaton 
Laboratories) against urinary tract infections, 
but with less tendency toward the consequent 
gastrointestinal disturbances reported by many 
patients. Because of the slower absorption rate, 
patients that could not tolerate Furadantin were 
able to accept Macrodantin capsules without 
the nausea. This slower absorption, however, 
apparently does not interfere with its effective- 
ness. The efficacy of oral Furadantin in cystitis 
and other specific urinary tract infections has 
long been recognized, and although its toxicity, 
particularly with respect to nerve damage and 
blood dyscrasias, is generally lower than that of 
other agents of equal potency, it has been as- 
sociated with nausea and vomiting in a signifi- 
cant number of reported cases. 

Nitrofurantoin macrocrystals differ from the 
microcrystals only in their physical properties. 
“Since nitrofurantoin is of limited solubility in 
water, it was hypothesized that an increase in 
size of the drug particles would retard its solu- 
tion rate significantly in, and consequently its 
absorption from, the alimentary canal. Slowing 
the drug’s entry into body fiuids, it was hoped, 
would lower its concentration peaks in serum 
and thereby decrease the incidence and severity 
of nausea and emesis, without significantly af- 


fecting its concentration in the urinary tract.”^ 
These two drugs have the same antibacterial 
spectrum, however, and are equally effective in 
the chronic and refractory infections of the 
urinary tract. Hailey and Glascock,^ in their 
collaborative study reported in 1967, found that 
of 112 patients who had experienced nausea and 
vomiting with Furandantin, only 20% showed 
similar reactions to Macrodantin. This repre- 
sents a considerable reduction and similar re- 
sults have since been reported by other clini- 
cians.- This study, although small in number, 
bears out these previous reports. 

In a previous study, in 1967, of simple cys- 
titis in women patients,'^ Furandantin was found 
to be 100% effective in sterilizing the urine in 
those patients with positive urine cultures on 
their first visit. The clinical cure rate, based on 
symptoms and signs of cystitis, was 91%. The 
study reported here was undertaken to determine 
whether Macrodantin would be equally as ef- 
fective in a group of similar patients. Acute 
cystitis is a common problem among women, 
particularly in women in their middle years. 
Failure to achieve prompt control can lead to 
ascending infection of a more resistant, or 
refractory, type. Thus it is important that the 
early medication be promptly effective, as well 
as innocuous to the general body system. Both 
actual and potential infection should be con- 
sidered. 

METHOD 

Our series included 53 women whose ages 
varied from 3 to 76 years, the majority ranging 
in age from 20 to 60 and the median in the 
fourth decade. With respect to parity status, 8 
of the patients had borne one child each, 29 
had borne more than one child, 10 were nulli- 
parous. The median of those whose parity was 
recorded as accurate was two. The remaining 
eight patients included in the study had no parity 
status recorded. 

There was a history of previous urinary tract 
infection in 42 cases. One patient had under- 
gone nephrectomy two years prior to the study. 
Various concomitant disorders were noted in 17 


MARCH, 1973 


217 


cases. These included vaginitis in three, and 
lumbosacral strain in two instances. In one case 
the presence of a cystocele was thought to con- 
tribute to the urinary bladder symptoms, es- 
pecially the presence of a pressure sensation. 

The patients commonly reported frequency 
of urination as the major symptom. Dysuria, 
urgency, burning sensation on urination, and 
the presence of pressure also were preponderant. 
Pain was noted in 24 instances and hematuria 
was present in 18. This includes two cases of 
acute hemorrhagic cystitis. 

The length of time the symptoms had been 
present before the patient sought medical as- 
sistance ranged from a few hours to three weeks. 
Most of the women sought help within the first 
week of symptoms. The onset of symptoms had 
been sudden and severe in 12 patients. (Table I) 

TABLE I 

SIGNS and SYMPTOMS: (in numbers of patients) 
Onset was sudden and severe in 12 patients. 



FIRST VISIT 

SECOND VISIT 

Dysuria 

49 

6 

Urgency 

49 

12 

Erequency 

53 

15 

Nocturia 

15 

2 

Spasms 

9 

0 

Tenesmus 

2 

0 

Hematuria 

18 

1 

Fever 

10 

0 

Pressure 

43 

19 

Pain 

24 

1 

Headache 

4 

0 

Other 

8 

1 


Urine specimens for bacterial culture and 
sensitivity studies were taken at the initial visit. 
These studies were repeated approximately one 
week following cessation of treatment. All speci- 


mens for culture were obtained by sterile 
catheterization of the urinary bladder per 
urethra. The study allowed that if there were 
patients who failed to respond to the macro- 
crystal form of nitrofurantoin (Macrodantin) 
within two to three days, the initial sensitivity 
tests would serve as a guide to alternate therapy. 
The usual treatment for the women included 
in this investigation consisted of Maerodantin 
eapsules, 50 mg, four times each day. The only 
exception to this regime was the single case of 
the three year old girl who was given a 50 mg 
capsule twice daily. The treatment period was 
for one week. 

RESULTS OF STUDY 
The first bacteriologic cultures of the urine 
were positive for growth in 28 instances, in 22 
of which there was significant bacteriuria 
(100,000, or more, per ml). 

Specifically, the organisms isolated were: 
Escherichia coli in 15; Klebsiella aerobacter in 
five; Proteus species in three; and Staphylococ- 
cus was present in one. In only one case was the 
organism not identified. All strains proved 
sensitive to Macrodantin with the exception of 
one Proteus and one Pseudomonas. (Table II) 
None of the patients with initially negative 
cultures showed any baeteriuria on the second 
culture. Among the other patients of the study, 
the urine had become sterile in all but six cases. 
In two instances where the first cultures had 
shown Pseudomonas aeruginosa and Klebsiella 
aerobacter respectively, the second cultures dis- 
closed Proteus instead. Similarly, Klebsiella 
aerobacter was found in the urine of a patient 
who had shown Escherichia coli in the first cul- 
ture obtained. Whether these changes from one 


TABLE II 


ORGANISM 

FIRST CULTURE 

SECOND 

CULTURE 


# of patients 
sensitivity 

# of patients 
insensitivity 

# of patients 
sensitivity 

# of patients 
insensitivity 

E. coli 

15 

0 

2 

0 

Proteus Species 

2 

1 

0 

2 

Pseudomonas aeruginosa 

2 

1 

0 

0 

j Klebsiella aerobacter 

5 

0 

2 

0 

Staphylococcus 

1 

0 

0 

0 

Totals 

25 

2 

4 

2 


218 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


bacteriuria to another represented reinfection or 
overgrowth could not be determined. The other 
three positive cultures represented a continuation 
of Escherichia coli. (Table III) 

TABLE III 

ORGANISMS WHERE INITIAL AND 
SECOND CULTURES ARE BOTH POSITIVE. 


FIRST CULTURE SECOND CULTURE 


Pseudomonas 

aeruginosa 

Proteus Species 

(180,000) 

Klebsiella 

Klebsiella 


aerobacter 

aerobacter 

(250,000) 

E. coli 

E. coli 

(120,000) 

E. coli 

Proteus Species 

(swarmed) 

E. coli 

Klebsiella 



aerobacter 

(50,000) 

E. coli 

E. coli (negative 

on Culture 


#3, two 

weeks later) 

Of the 53 

cases, 48, or 91%, 

were rated 


clinically and bacteriologically following the 
Macrodantin treatment regime. Three patients 
were clinically improved, whereas two were 
considered to be failures. Patients reported 
generally that their symptoms were cleared, or 
greatly improved, within three to six days of 
treatment. This was true even in cases where a 
bacteriological cure required a second course of 
Macrodantin treatment. In one of the two 
clinical “failures,” symptoms improved but 
hematuria continued, with evidence of upper 
tract inflammation. In this case the urine cul- 
tures collected were negative. In the second 
“failure,” Escherichia coli cleared from the urine 
within two weeks, for a bacteriologic cure, but 
the clinical response to the drug was unsatisfac- 
tory. 

Adverse reactions were noted in four in- 
stances: mild diarrhea which was treated 

specifically while continuing the Macrodantin; 
mild nausea which was also treated without the 
cessation of the Macrodantin; severe nausea 
which required the discontinuance of the Macro- 
dantin therapy; and one skin rash which oc- 
curred in a patient that also reported “a nervous 
twitch” and showed signs of hyperirritability, 
dictating cessation of the drug. It is interesting 
to note that in the last two cases, when Macro- 
dantin was discontinued after four days of treat- 
ment, the urinary tract symptoms had already 


cleared. Both of these cases were reported as 
clinical cures. 

DISCUSSION 

“Mechanical self sterilization of a normal 
urinary tract is accomplished by a high flow rate 
in the renal pelvis and ureter as well as by a 
frequent complete emptying of the urinary 
bladder. Bacteria, once introduced into such a 
normal tract, can survive only by invading these 
tissues. These bacteria will remain and thrive 
either within the urine or the tissues unless local 
defense mechanisms succeed in destroying 
them.”^ If the bacteria survive within the 
epithelium despite these natural defenses, the 
inflammatory reaction will likely give rise to 
urinary symptoms or signs. Bacteriuria may or 
may not be present even though inflammation 
of the tissues has occurred, giving rise to cys- 
titis. Moreover, pathogens identified in the urine 
may not be the actual cause of the inflammation 
existing in the epithelium. Reports from etio- 
logic studies remain inconclusive, despite ex- 
haustive efforts to detect viruses, fungi, or 
bacteria other than the usual coli-aerogenes 
group. Hanash and Pool,° for example, in study- 
ing sixty patients, of which 54 were women, with 
either interstitial or hemorrhagic cystitis, applied 
specific and selective culture methods to tissue 
and urine specimens, with negative results. Their 
findings, they said, did not exclude the possibility 
that the lesions were caused by a virus or fungus 
that could not be isolated by current techniques. 

The most effective therapy would thus be a 
drug which penetrates the tissues rather than 
remaining exclusively in the urine adjacent to 
susceptible tissue. Nitrofurantoin is capable of 
penetrating deeply into the bladder wall. This 
trait in part explains the drug’s effectiveness in 
the medical management of cystitis. Apparently 
Macrodantin is as effective as Furadantin in the 
treatment of cystitis, even though it has a slower 
rate of absorption due to its larger crystalline 
size. This study would indicate that the side 
effects are, in most cases, mild. Conclusions 
regarding the relative frequency of side effects 
cannot be drawn from the series reported here, 
although the results suggest agreement with 
those reported for specific comparative studies 
which show that the macrocrystalline form is 
more readily tolerated.^’ ^ Bacterial resistance 
to Nitrofurantoin is evidently an infrequent oc- 
currence and has not shown any tendency to 
increase over the last few years. 


MARCH, 1973 


219 


SUMMARY 


Nitrofurantoin macrocrystals (Macrodantin, 
Eaton) in capsule form were administered to 
53 female patients with signs and symptoms of 
acute cystitis. The result of this study was that 
48, or 91%, were rated as clinically and bacte- 
riologically cured. Culture studies revealed sig- 
nificant bacteriuria in 22 cases at the onset. 
Following Macrodantin treatment five of the 
patients had urine cultures positive for growth. 
Clinical response to therapy occurred within 
three to six days. There were four instances of 
mild side effects from the drug, one of which 
may or may not have been related to the drug 
therapy. Although the reactions caused the 
therapy to be discontinued in two cases, the 
judgment was that these were already clinically 
cured by the time the treatment was discon- 
tinued. 

Since symptomatic relief of acute cystitis is 
not necessarily related to signs of urinary infec- 
tion, the effectiveness of Nitrofurantoin is 
thought to be due, in part, to its ability to exert 
antibacterial and anti-inflammatory effects within 
the tissues of the bladder wall. The high inci- 
dence and the promptness of clinical response to 
Nitrofurantoin therapy in acute cystitis attest to 
the efficacy of this broad-spectrum antibacterial 
agent, even though a bacterial cause-and-effect 
relationship cannot always be demonstrated. 

The rapid relief of symptoms following the 
use of Macrodantin negates the need for analge- 
sics or azo-dye preparations and makes single 
drug therapy with Nitrofurantoin macrocrystal 
a practical choice in the treatment of simple 
cystitis in women. 

Medical Center Court 
Clarksville, Tenn. 37040 

REFERENCES 

1. Hailey, FJ, and Glascock, HW, Jr.: “Gastroin- 
testinal Tolerance to a New Macrocrystalline Form 
of Nitrofurantoin: A Collaborative Study.” Current 
Therapy Research, 9:600, Dec., 1967. 

2. Shirley, S.W. and Ozog, LS: “Improved Gastro- 
intestinal Tolerance to Nitrofurantoin in the Macro- 
crystal Form.” Urology Digest, 9:8-10, July, 1970. 

3. Malone, FJ Jr.: “Furadantin in the Treatment of 
Simple Cystitis in Women.” Memphis and Mid-South 
Med J, August, 1967 (technical note). 

4. Gibbon, NOK: “The Management of Recurring 
Urinary Tract Infection in the Female.” S Afr Med 
J. 46:246-248, March, 1972. 


5. Hanash, KA and Pool, TL: “Interstitial and 

Hemorrhagic Cystitis; Viral, Bacterial, and Fungal 
Studies.” J of Urol 104:705-706, November, 1970. 

6. Dodson, Al and Hill, IF: “Use and Misuse of 
Antibiotics in the Treatment of Infections of the 
Urinary Tract.” Va Med Monthly, 82-385-388, Sep- 
tember, 1955. 


In 1933 Robert Aldrich, working with Firor 
at Johns Hopkins, published a classical article 
in the New England Journal of Medicine, in 
which he expressed the thought that “there is 
enough infection in the burn area to account 
for all the symptoms and physical signs” that 
physicians had been ascribing to the “tox- 
emia” which occurred, supposedly, as a result 
of thermal injury. Today, unfortunately, his- 
tory repeats itself and the subject of “toxemia” 
is coming back to the fore. Many are still try- 
ing to implicate nebulous toxins in the problems 
of the burn patient. 

“Fifty Years Progress in Burns,” John A. Moncrief, 
M.D., CACS — Reprinted from the Bulletin of The 
American College of Surgeons, June, 1972. 


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220 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Recognition of Curable 
Forms of Hypertension 

GRANT W. LIDDLE, M.D., RONALD D. BROWN, M.D., VICTORIA R. LIDDLE 


All physicians are aware that hypertension 
is one of the major causes of death and dis- 
ability in the United States. It has become 
increasingly apparent during the past few de- 
cades that hypertension itself has many causes. 
An increasing number of clinical entities giving 
rise to hypertension have been elucidated, spe- 
cific methods for diagnosing them have been 
developed, and in several specific treatments 
have become available which make it possible 
to correct the hypertension. Although drug 


therapy in hypertension has also advanced 
greatly during the past 20 years, it is still 
desirable to identify curable hypertension and 
cure it when possible rather than to treat all 
patients alike, as though they all had chronic, 
incurable essential hypertension. 

We have devised a simple system to guide 
physicians in screening for curable hyper- 
tension (Table 1). Some of the causes of 
hypertension can be ruled out by history alone, 
others by a cursory physical examination, still 


HYPERTENSION WORK UP CHECK LIST AND REGISTRY FORM 








DATE 


NAME 




BIRTHDATE 


HOSP. CHART NO. 


ADDRESS 




AGE SEX RACE 


WT. HT. 


REFERRING 

PHYSICIAN 







INITIAL 

BP: LEFT 

ARM 


RIGHT ARM 


LEG 




Screened for 

Date 




Date 

Etiology 


by Finding of: 

of Test 

Result Confirmed by: 



of Test Result 


Oral Contraceptives 

History of 
faking O.C. 


Yes. 

No 

Licorice Intoxication 

Eats large amounts of 
licorice 


Yes 

No 

Coarctation of Aorta 

BP in legs less than 
in arms 


Yes 

No 

Congenital ll OH-lase Delic. 

Adrenal - 

Virilism 


Yes 

No 

Hyperplasia 17 0H lase Defic. 

Sexual Infantilism 


Yes^ _ 

No 

Cushing’s Syndrome 

Obesity 


Yes 

No 

Primary Aldosteronism 

Hypokalemia 
(K+ _ mEq;L) 


Yes 

No 

Pseudoaldosieronism 

Hypokalemia 
(K^ . inEq'L) 


Yes 

No. 

Cryptic Mineralocorticoid Excess 

Low PRA after Furosemide 
(PR A: ng/ml/hr) 


Yes_ 

No 

Pheochromocytoma 

Elevated VMA 
(VMA. ing/24 hr) 


Yes_ 

No 

Renal Artery Stenosis 

Abnormal rapid 
sequence IVP 


Yes_ 

No_ 

Obstructive Uropathy 

Obstruction visualized 
on IVP 


Yes__ 

No 

Primary Renal Disease 

Abnormal urinalysis. 
RBC. ; Prot ; Bact. 


Yes_ 

No 

Essential hypertension 

None of 
above 


Yes_ 

No_ 


Normoiensioo after stop taking O.C. for two months 


Yes_. No _ 

Normoiension after stop eating licorice for one month 


Yes -- No_^. 

Abnormal aortogram 


Yes No 

High urinary 17-OH and 17-KS ( .mg/24 hr: mg/24 hr} 

Suppressed by Dexameth. 0.5 mqq6h ( mg/24 hr; mg/24 hr) 


Yes__ No. - 
Yes _ . No .. , 

Low urinary 17-OH and 17-KS ( mg/24 hr; mg/24 hr} 

High plasma 00 C ( nq%) 


Yes . No- 
Yes — No.. 

High urinary 17-OH ( mg/24 hr.) 

Resisted suppression with Dexameth. 0.5mgq6h ( mg/24 hr.) 


Yes. -- No 

Yes . . No . -- 

Low plasma renin activity { ng/ml/hr} 

High urinary aldosterone excretion ( pg/24 hr.} 


Yes No--- 

Yes- - No- 

Low plasma renin activity ( ng/ml/hr} 

Low urinary aldosterone excretion ( ;jg/24 hr.} 


Yes _ No__ 
Yes__ No _ _ 

Response to spironolactone 400 mg daily for six weeks 


Yes No . _ 

Elevated catecholamines (_ mg/24 hr) 

Elevated metanephrines ( my/24 hr) 


Yes No^ 

Yes No_ 

Stenosis on renal arteriogram 

Renal vein renin ratio greater than 1.5 (ratio. } 

Split renal function abnormal 


Yes No_ _ 

Yes No 

Yes_ No_ _ 

Normotension after correction of obstruction 


Yes _ No _ _ 

Elevated BUN ( mg%) or creatinine (_ mg%) 

Positive urine culture 
Abnormal IVP 


Yes. _ No__ . 

Yes No 

Yes__. No_ 

None of above 


Yes. No 


FINAL DIAGNOSIS 


Table 1 


* From the Department of Medicine, Vanderbilt 
University School of Medicine, Nashville, Tenn. 37203 
USA. 

Supported by Tennessee Mid-South Regional Medi- 
cal Program Project #48. 


Others by a few simple laboratory tests, and the 
remainder by an x-ray examination. When this 
check list has been filled out with negative 
answers it would seem reasonable to proceed 
with nonspecific therapy. Until all of the ques- 


MARCH, 1973 


221 


tions have been answered, one should not be 
satisfied that his patient is receiving the best 
medical care that is available. 

Beginning with the medical history, two of 
the curable causes of hypertension can be 
ruled out simply by ascertaining whether or 
not the patient has been taking oral contra- 
ceptives’ or large amounts of licorice.- If the 
hypertensive patient has been taking either of 
these agents, it might be responsible for ele- 
vating the blood pressure. Cessation of oral 
contraceptives or licorice should be followed by 
normalization of blood pressure within a few 
weeks. If the blood pressure does not return 
to normal, other causes of hypertension must 
be considered. 

Several other causes of hypertension can be 
ruled out during the physical examination. 
Coarctation of the aorta as a cause of hyper- 
tension can be excluded if the blood pressure 
in the thighs is higher than that in the arms. 
If it is not, coarctation must be suspected. The 
definitive diagnosis is established by aortogra- 
phy, and surgical correction of the coarctation 
should relieve the hypertension. 

There are two varieties of congenital adrenal 
hyperplasia that give rise to hypertension. One 
of these (due to 1 l^S-hydroxylase deficiency) 
gives rise to virilism'^ and the other (due to 
17 a-hydroxylase deficiency) is associated with 
sexual infantilism.'’ Therefore these causes of 
hypertension can be ruled out by noting that 
there was no virilization during childhood and 
no unusual delay in development of secondary 
sex characteristics during adolescence. On the 
other hand, hypertensive patients who show 
evidence of excesses or deficiencies of sex 
hormones should be suspected of having con- 
genital adrenal hyperplasia. Those with virilism 
will be found on further study to have elevated 
urinary 17-hydroxycorticosteroids and 17- 
ketosteroids and elevated plasma concentrations 
of 1 1 -deoxycorticosterone, all of which can be 
suppressed by treatment with dexamethasone in 
doses of 0.5 mg every 6 hours. Those with 
sexual infantilism will be found on further 
study to have low urinary 17-hydroxycorticos- 
teroids and 17-ketosteroids; their plasma levels 
of 1 1 -deoxycorticosterone will be elevated. In 
either variety of hypertensive congenital adrenal 
hyperplasia, the overproduction of 11 -deoxy- 
corticosterone and, therefore, the hypertension, 
can be controlled by long term treatment with 
dexamethasone or hydrocortisone in doses just 

222 


sufficient to suppress pituitary-adrenal function 
to normal. 

Cushing’s syndrome, when curable, is almost 
always associated with some degree of cen- 
tripetal obesity.'^ (When Cushing’s syndrome 
is associated with metastasizing malignancy, 
the obesity that is so familiar a part of the 
syndrome is often lacking.) Therefore, if the 
hypertensive patient is not obese, tests for 
Cushing’s syndrome will almost always be 
unrewarding. If the hypertensive patient ex- 
hibits obesity or other features of Cushing’s 
syndrome, the diagnostic evaluation should 
include a measurement of urinary 17-hy- 
droxycorticosteroids. If these are elevated a 
dexamethasone suppression test should be per- 
formed. Profound suppression of 17-hydroxy- 
corticosteroids with 0.5 mg of dexamethasone 
every 6 hours effectively excludes the diag- 
nosis of Cushing’s syndrome. Failure of such 
suppression is strong evidence in favor of the 
diagnosis. Cushing’s syndrome and the ac- 
companying hypertension can usually be cor- 
rected by removing the abnormal source of 
cortisol (adrenalectomy) or of ACTH (pi- 
tuitary ablation or removal of a tumor that 
secretes ectopic ACTH). 

Considering the relatively small number of 
cases that have been discovered, primary 
aldosteronism has received an impressive 
amount of attention in the medical literature 
during the past seventeen years. It is important 
because it illustrates a classical mechanism of 
hypertensive disease and because it is one of 
the curable causes of hypertension. Although 
“normokalemic primary aldosteronism” is a real 
entity, it is so rare and so difficult to diagnose 
that it is of little more than academic interest 
to the physician attempting to deal in a prac- 
tical manner with uncategorized hypertensive 
patients. For practical purposes, any hyper- 
tensive patient who has intermittent or per- 
sistent unprovoked hypokalemia should be 
suspected of having primary aldosteronism. 
Diuretic therapy, vomiting, or diarrhea, may 
provoke hypokalemia, and the question can 
be settled by observing the serum potassium 
on several occasions when such factors as these 
are not operative. The diagnosis of primary 
aldosteronism is established when it is dem- 
onstrated that under standard conditions the 
patient has subnormal plasma renin activity 
and high urinary aldosterone excretion.® Ap- 
propriate treatment is usually the surgical re- 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


moval of an adrenal adenoma.' If no adenoma 
can be found, IV 2 adrenal glands should be 
removed, followed, if necessary, by treatment 
with the aldosterone antagonist, spironolactone^. 
Complete or partial correction of the hyper- 
tension occurs within two months in the great 
majority of cases. 

“Pseudoaldosteronism” is a familial renal 
disorder which simulates primary aldosteronism 
in causing hypertension, hypokalemia, and 
suppression of plasma renin activity,® but 
aldosterone secretion rates are very low. The 
condition might be suspected in a hypertensive 
patient with a family history of this disorder. 
(A large kindred has been encountered in the 
Southeastern United States.) Otherwise, the 
diagnosis is likely to be established when one 
finds a patient who has the features of primary 
aldosteronism but has low rather than high 
aldosterone. The hypertension and hypokalemia 
can be corrected by treatment with triamterene; 
no other agent has been found effective in this 
particular disorder. 

“Cryptic mineralocorticoid excess” is the 
name that has been applied to the syndrome 
of “essential hypertension with suppressed re- 
nin.”'^ Approximately 20 percent of hyper- 
tensive patients fall into this category. It is 
important to recognize because the hyper- 
tension responds to specific treatment with the 
mineralocorticoid antagonist, spironolactone.®'^^ 
It is partly on the basis of this response that 
the syndrome is thought to stem from an excess 
of some unidentified mineralocorticoid, hence 
the term “cryptic mineralocorticoid excess.” 
Once the hypertension has been reduced with 
large doses of spironolactone, it can be con- 
trolled indefinitely with doses of 100 to 200 
mg per day.® 

Most physicians who have had broad experi- 
ence with pheochromocytomas consider that a 
complete hypertension evaluation should in- 
clude a screening test for urinary catecholamines 
or catecholamine metabolites. Patients with 
pheochromocytomas almost always have values 
above the upper limit of normal, regardless 
of whether one measures catecholamines, VMA, 
or metanephrines.^- Therefore, any one of these 
may be used for screening. If a high value is 
obtained, it should be confirmed by measure- 
ments of the other two modalities. If these are 
also high, it is generally advisable to place the 
patient under the care of a medico-surgical 
team with a good record of success in man- 


aging pheochromocytoma, since this treacherous 
disease is often fatal if improperly managed. 
In recent years the surgical treatment of 
pheochromocytoma has been simplified by 
the availability of alpha-adrenergic blocking 
agents, which control the pressor effects of 
catecholamines, and beta-adrenergic blocking 
agents,^® which can be used to prevent cate- 
cholamine-induced cardiac arrhythmias. Prop- 
erly treated, the hypertension of pheochromo- 
cytoma is almost always correctable. 

Although in the past a variety of suggestions 
have been made as to when the physician 
should be alert to the possibility that a patient 
might have correctable hypertension secondary 
to renal artery stenosis, it is now apparent that 
all of these rules would neglect a substantial 
proportion of such patients. It can occur in 
any age group, and, if unrecognized and un- 
corrected, it can lead to chronic hypertension. 
It occurs in patients with or without a family 
history of hypertension, and it may or may not 
be accompanied by abdominal bruits. Since 
it may account for 5% of our hypertension 
problem, it clearly should not be overlooked. 
The screening test that is most acceptable is 
the “rapid sequence intravenous pyelogram.” 
Radiographic films taken 2, 4, or 6 minutes 
after the contrast medium is injected might 
show delayed opacification of the calyceal 
system of the kidney supplied by a stenotic 
artery. Later films taken at 10 or 15 minutes 
might show delayed “washout” on the same 
side. The affected kidney might also be 
measurably smaller than the unaffected one. 
Abnormalities such as this call for expert renal 
arteriography which should demonstrate the 
area(s) of stenosis. The functional significance 
of an area of renal artery stenosis should be 
confirmed by split renal function studies^® or 
by bilateral renal vein renin measurements 
showing discrepancies between the two sides^® 
consistent with diminished renal blood flow 
and increased renin production on the side with 
the significantly stenosed renal artery. With 
such evidence in hand, the experienced reno- 
vascular surgeon can confidently expect com- 
plete or partial correction of hypertension 
following corrective surgery in a very high 
percentage of cases. 

In obtaining a medical history, performing 
a physical examination, or performing intra- 
venous urography, one may encounter evidence 
of obstructive uropathy which if corrected 


MARCH, 1973 


223 


might iead to the cure of hypertension.^^ 

Many varieties of renal disease in addition 
to those mentioned above can cause hyper- 
tension. Even if they are not correctable, they 
deserve recognition so that the physician will 
be in a position to manage the patient’s total 
problem, not merely the hypertension, more 
intelligently. For this reason every complete 
hypertension evaluation should include such 
things as a routine urinalysis and a blood urea 
nitrogen. 

The screening procedures outlined in Table 
1 are not formidable or expensive if one con- 
siders all that is at stake in recognizing or 
failing to recognize a curable cause of hyper- 
tension. Most of the screening studies can be 
completed or initiated during 2 office visits 
if one proceeds in an orderly fashion. 

It is now apparent that a sizeable minority 
of patients with hypertension can be cured or 
effectively treated. One should not become dis- 
couraged by the fact that it is only a minority: 
for, if the physician ceases to look for curable 
hypertension, then not just a majority but all 
of his hypertensive patients will be incurable. 

REFERENCES 

1. Laragh, JH, Sealey, JE, Ledingham, JGG, and 
Newton, MA: Oral Contraceptives. JAMA, 201:918, 
1967. 

2. Conn, JW, Rovner, DR, and Cohen, EL: Licorice- 
induced Pseudoaldosteronism. JAMA, 205:492, 1968. 

3. Bongiovanni, AM, Eberlein, WR, Goldman, AS, 
and New, M: Disorders of Adrenal Steroid Biogenesis. 
Rec Prog Hormone Res, 23:375, 1967. 

4. Biglieri, EG, Herron, MA, and Brust, N: 17- 

Hydroxylation Deficiency in Man. J Clin Invest, 45: 
1946, 1966. 

5. Liddle, GW, Adrenal Cortex, Beeson, PB, and 
McDermott, W, (eds.) Cecil-Loeb Textbook of Medi- 
cine (Philadelphia: W.B. Saunders Co., 1971), pl781. 

6. Conn, JW, Cohen, EL, and Rovner, DR: Sup- 

pression of Plasma Renin Activity in Primary Aldos- 
teronism. Cli Sci, 190:213, 1964. 

7. Liddle, GW: Management of Aldosteronism. 

Amer J Clin Path, 54:331, 1970. 

8. Liddle, GW: A Familial Renal Disorder Sim- 

ulating Primary Aldosteronism But With Negligible 
Aldosterone Secretion. Trans Ass of Am Phys, 76:199, 
1963. 

9. Carey, RM, Douglas, JG, Schweikert, JR, and 
Liddle, GW: The Syndrome of “Essential Hyperten- 
sion and Suppressed Plasma Renin Activity.” Arch 
hit Med, (in press). 

10. Crane, MG, and Harris, JJ: Effect of Spirono- 


lactone in Hypertensive Patients. Amer J Med Sci, 
260:311, 1970. 

11. Spark, RE, and Melby, JC: Hypertension and 

Low Plasma Renin Activity: Presumptive Evidence 

for Mineralocorticoid Excess. Ann hit Med, 75:831, 
1971. 

12. Sjoerdsma, A, Engelman, K, Waldmann, TA, 
Cooperman, LH, and Hammond, WG: Pheochromocy- 
toma: Current Concepts of Diagnosis and Treatment. 
Ann hit Med, 65:1302, 1966. 

13. Ross, EJ, Prichard, BNC, Kaufman, L, Robert- 
son, AIG, and Harries, BJ: Preoperative and Opera- 
tive Management of Patients with Phaeochromocytoma. 
Brit Med J, 1:191, 1967. 

14. Foster, JH, Oates, JA, Rhamy, RK, Klatte, EC, 

Pettinger, WA, Burko, H, Younger, RK, and Scott, 
HW: Detection and Treatment of Patients with 

Renovascular Hypertension. Surg, 60:240, 1966. 

15. Howard, JE, and Connor, TB: Use of Differ- 
ential Renal Function Studies in the Diagnosis of 
Renovascular Hypertension. Amer J Surg, 107:58, 
1964. 

16. Michelakis, AM, Foster, JH, Liddle, GW, 
Rhamy, RK, Kuchel, O, and Gordon, RD: Measure- 
ment of Renin in Both Renal Veins. Arch Intern Med, 
120:444, 1967. 

17. Garrett, J, Poise, SJ, and Morrow, JW: Ureteral 
Obstruction and Hypertension. Amer J Med, 49:271, 
1970. 


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Phone: 713/453-6324 


224 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


/Iciff COAfefttACe 


TRIGEMINAL NEURALGIA 
Vanderbilt University Hospital* 

DR. WILLIAM MEACHAM; Today, we 
are considering a clinical problem that has pro- 
duced a vast amount of suffering and acute 
discomfort throughout the ages, a disorder that 
has baffled interested clinicians and researchers 
for years and for which no specific cause has yet 
been discovered. It is one which lasts intermit- 
tently for years, producing only the subjective 
symptom of pain without loss of function and 
without deleterious effects on the total body 
health except indirectly. This strange and 
peculiar disorder, known as tic douloureux, 
trigeminal neuralgia, or trifacial neuralgia, was 
hrst described as a clinical entity in 1776 by 
Fothergill, and for a while was known as 
Fothergill’s disease. The intensity of the painful 
attacks experienced by victims of this disorder 
has resulted in its attaining the dubious reputa- 
tion of being the most severe pain to which 
humans are heir. Those of us who have wit- 
nessed the desperation of these patients and 
their willingness to undergo almost any operative 
procedure, however uncomfortable or even de- 
forming, in the hope of securing relief can at- 
test to its horrible severity. Dr. Robert LeGrand 
will present the pertinent history on the patient 
for discussion today. 

DR. ROBERT LEGRAND: The patient is a 65 

year old right-handed Cuban female who was ad- 
mitted to Vanderbilt University Hospital on Septem- 
ber 6. 1972 with a chief complaint of “face pain.” 
Eor the past two years, she had intermittent, brief, 
lancinating pains originating in the right upper alveolar 
ridge area with distribution over the 2nd division of 
the right trigeminal nerve. Any stimulation of this 
area would induce the facial pain. A trial of diphenyl- 
hydantoin (Dilantin) was given without pain relief. 
This was followed by administration of carbamazepine 
(Tegretol), which did produce relief, but had to be 
discontinued because of leukopenia. In the past sev- 
eral weeks, the attacks have become more frequent and 
more severe. There is no history of infectious process 
or trauma to the face and head area. 

Her past history is significant only in that she had a 
cardiac irregularity for an unknown period of time and 
has been treated with quinidine recently. An abdom- 


*Erom the Department of Surgery, Division of 
Neurological Surgery, Vanderbilt University School 
of Medicine. Nashville, Tenn. 


inal hysterectomy and cholecystectomy were done in 
Cuba many years ago. 

Physical examination on admission revealed an ir- 
regular pulse of 85 per minute, blood pressure 130/70, 
respirations 14 per minute, and temperature 98.6° F. 
orally. She was a well-developed, well-nourished, 
Spanish-speaking woman. Examination of the heart 
revealed an irregular rhythm without murmurs or 
evidence of cardiomegaly. Right subcostal and lower 
midline abdominal surgical scars were present. The 
remainder of the general physical examination and the 
neurological examination were within normal limits. 
Specifically, there was no sensory or motor abnor- 
mality involving the right trigeminal nerve distribution. 
Skull films, including basilar views, were normal ex- 
cept for hyperostosis frontalis interna. Initial EKG 
revealed atrial fibrillation and a complete left bundle 
branch block. 

On September 8, as the patient was being given 
sodium thiopental for induction of anesthesia, the 
heart rate was noted to be 150-180 per minute with 
a single short episode of what was thought to be 
ventricular tachycardia. Surgery was canceled. Follow- 
up EKG’s showed no change from the admission 
EKG, and serial SGOT and CPK determinations were 
normal. The quinidine was discontinued, and she was 
digitalized with digoxin. The heart rate remained 
stable at 70-80 per minute. On September 11, she 
underwent right temporal craniectomy and middle 
fossa exploration with retrogasserian section of the 
2nd division of the trigeminal nerve. Postoperatively, 
she has had a smooth course, except for a herpetic 
eruption in the right infraorbital area and right upper 
lip, occurring on the fifth postoperative day. 

DR. MEACHAM: I think we all would 

judge this to be a case of classical trigeminal 
neuralgia characterized by the usual features of 
brief, acute, repetitive, lacinating pains in the 
distribution of one or more branches of the 
trigeminal nerve, followed by pain free remis- 
sions of varying lengths of time, and by the 
presence of trigger shots, or dolorogenic zones 
of Patrick. Note that the trigeminal nerve was 
normal on examination. These features, there- 
fore, make the diagnosis by subjective rather 
than objective means. 

As one would anticipate, a long and disap- 
pointing experience has accumulated throughout 
the years in the hopes of finding a specific and 
harmless medical cure for this painful affliction. 
The occurrence of long periods of spontaneous 
remission of the pain has led many to claim 
curative effects for many nostrums and combi- 
nations of drugs, but without real benefit being 
proven. Ferrous carbonate, trichlorethylene, 
vitamin B^o, stilbamidine, and others have had 
a period of brief popularity. More recently, the 
anticonvulsants have been employed with some 
success — notably Dilantin, and currently, Tegre- 


MARCH, 1973 


225 




tol seems to be specifieally helpful in many 
patients, but there are those who cannot take 
this drug because of undesirable reactions to it 
or in whom the effectiveness seems to be at- 
tenuated. The surgeon, therefore, is still called 
upon to carry out some pain relieving operative 
procedure on the trigeminal sensory system. As 
you have heard, this patient has been subjected 
to an intracranial operative procedure that 
would be considered a slight modification of 
the classical surgical procedure in use for many 
years. Dr. Cobb, will you discuss the middle 
cranial fossa operative procedure for trigeminal 
neuralgia? 

DR. CULLY COBB: This lady had an op- 
eration which is a slight modification of the 
most time tested surgical treatment for tic 
douloureux. In 1901, Spiller and Frazier first 
published a description of the operation, point- 
ing out the necessity for dividing the sensory 
root proximal to the ganglion in order to secure 
permanent relief of the pain. The elevation of 
the dura of the temporal fossa, exposing the 
ganglion and opening Meckel’s cave for a section 
of the sensory rootlets was the basis of the pres- 
ent day operation. In this patient, we were 
careful to select fibers directed toward the lower 
third or lower one-half of the maxillary division. 
This was done because the trigger zone was in 
the upper lip and small adjacent area of the 
nose. Although a number of fibers were divided, 
there is no complete anesthesia. Sensation in 
the tongue and lower lip as well as in the cornea 
is intact. This idea of preserving sensation 
except in the region where the pain is triggered 
by touch, was suggested by Frazier in 1925. 
The fibers directed toward one of the three 
major divisions would be divided. The discovery 
that manipulation of the ganglion by decom- 
pression or compression procedures might some- 
times give permanent relief, and also the 
experience of observing the unpleasantness and 
sometimes serious complications of extensive 
section of the sensory root, have led to in- 
creasingly focal sectioning of the sensory root- 
lets. In this patient’s case, the slightly vertical 
position of the ganglia made it unusually easy to 
identify the appropriate nerves and also to 
identify the motor root, a larger nerve lying 
behind the sensory rootlets following a more 
vertical course toward the foramen ovale. 

I don’t believe there have been any recur- 
rences with our patients who had this operation 
except for one who developed tic douloureux on 

226 


the opposite side. A number of years ago, 
Francis Grant reported an incidence of recur- 
rence of pain in 7.5% of almost 600 patients 
who had a differential partial rhizotomy. With 
the help we now have from drugs such as 
Dilantin and Tegretol, 1 feel that some slight risk 
of recurrence is much preferable to the trouble- 
some eomplications which sometimes may follow 
extensive or complete section of the sensory root. 

DR. MEACHAM; Dr. Cobb has outlined 
the procedure perfected and popularized by 
Frazier, Cushing, Peet, Sachs, and others — and 
the one most often employed in this clinic. 
However, certain benefits were thought by Dr. 
Walter Dandy of Johns Hopkins to be obtained 
by using a posterior fossa approach to the 
trigeminal posterior root, a concept now being 
pursued with renewed interest since the advent 
of the operating miscroscope. Dr. Meirowsky 
has preferred the posterior fossa operation and 
he will discuss the merits of this technic. 

DR. ARNOLD MEIROWSKY: It has been 
my practice to employ differential section of 
the posterior root of the fifth cranial nerve in 
the cerebellopontine angle, as was first described 
by Walter Dandy in 1925. By using the lateral 
recumbent, modified “Mount” position, and by 
instituting continuous spinal drainage during the 
operation, excellent exposure of the fifth cranial 
nerve can be obtained. In recent years, I have 
used the surgical microscope when doing the 
actual differential section of the nerve, finding 
that its employment affords substantial improve- 
ment of the surgical technique. 

The main advantages of this approach have 
been clearly defined by Dr. Dandy in his original 
writings. The distinct preservation of sensory 
perception in the face represents the most im- 
portant advantage. The fact that a substantial 
degree of skin sensation can be preserved by 
doing the differential section of the nerve close 
to the pons, was clearly and lucidly pointed out 
by Dandy in 1925, belittled by many in subse- 
quent years and experimentally proved by Peter 
Jannetta recently. Having had the opportunity 
of reexamining some of my patients five, ten, 
fifteen, and twenty years after surgery, I have 
found persistent relief of pain and equally per- 
sistent preservation of a considerable degree 
of eutaneous sensory perception in all of them. 

DR. MEACHAM: Probably one reason for 
the posterior approach being used so infre- 
quently in the past has been the concern about 
an increased morbidity, since this technic in- 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


volves a longer operation and involves a some- 
what greater risk, espeeially in the very elderly. 
There have been, however, other innovative 
surgieal attempts to relieve the pain and yet 
preserve facial sensation. Most of us have 
employed, at one time or another, the operation 
of trigeminal decompression, which Dr. 
Scheibert has employed frequently. 

DR. DAVID SCHEIBERT: The incidence 
of trigeminal neuralgia requiring surgical relief 
should now be increasing after the initial intro- 
duction of Tegretol. The Taarnhoj procedure or 
trigeminal decompression by the intradural ap- 
proach, as modified by Wilkins, has proven a 
good and usually lasting surgical method for the 
relief of trigeminal neuralgia. 

The reason for the effectiveness of the trigemi- 
nal decompression is not obvious, although 
there is certainly some degree of compression 
of the ganglion and massage of the trigeminal 
root in carrying out the procedure. Thus far, 
there have been no recurrences of neuralgia in 
those patients so treated by decompression over 
an eleven-year period. The primary advantage 
to trigeminal decompression is the usual saving 
of almost, if not all, of trigeminal function, 
particularly in those cases with ophthalmic in- 
volvement. The absence of recurrence has been 
gratifying, but should recurrence present itself, 
another type of surgical approach can be used 
easily. 

Complications with the intradural approach 
to the trigeminal decompression are minimal, 
but this approach is probably attended by a 
slightly higher morbidity in terms of drowsiness 
and headache and occasionally dysphasia when 
the dominant side of the brain is involved. 
However, retraction can be minimized by use 
of mannitol or urea. Of approximately thirty 
patients, one, a male in his seventies, developed 
a progressive intracerebral temporal hematoma 
three days after surgery with loss of life in spite 
of surgical evacuation of the hematoma. Diplo- 
pia has occurred temporarily in one patient and 
possibly permanently in one, with diplopia being 
of vertical nature in spite of visualization of the 
trochlear nerve which was intact. In both cases 
with diplopia, Tegretol had been used previ- 
ously. Herpetic lesions tend to occur with the 
same frequency as seen in other surgical ap- 
proaches to the neuralgic problem. In one 
patient, serious impairment of ophthalmic sensa- 
tion occurred with an annoying hypersensitivity 
of the lips. 


Important points in surgical technique would 
seem to be operating in the lateral supine posi- 
tion along with use of mannitol or urea to aid 
in operative exposure. The advent of angled 
clips has made clipping of the petrosal sinus 
easier with less danger of damage to the trigemi- 
nal root. Posterior incision through the free 
edge of the tentorium should be far enough 
back to avoid damage to the trochlear nerve as 
it enters the tentorium and one cannot help 
but wonder whether this posterior extension is 
necessary. Again the primary advantage of the 
trigeminal decompression would seem to be the 
ability to relieve pain while leaving neurological 
function fairly intact. It is possible now to 
secure this same effect by a “non-operative” 
method of electrodessication of the ganglion 
cells, but it has not yet been employed here to 
my knowledge. 

DR. JAMES HAYS: This form of treatment 
for trigeminal neuralgia is fairly new and has 
not been utilized in this area. This is done by 
the stereotactic placement of an electrode in the 
ganglion and the use of radiofrequency to pro- 
duce the lesion. Accurate placement of the 
probe helps produce a segmental lesion and con- 
trol of the temperature at the lesion preserves 
touch, motor, and proprioceptive functions and 
produces hypalgesia. This technique was used 
first for patients thought to be unsuited as candi- 
dates for the standard surgical procedures, but 
now, in some areas, it is being used as the 
primary treatment procedure. I am not aware 
of specific complications that have been de- 
scribed with the radiofrequency technique, but 
I would presume they would be similar to those 
observed with the other treatment methods. 

DR. RAY HESTER: In addition to the 

usual complications associated with any opera- 
tion, such as infection and hemorrhage, there 
are several things peculiar to rhizotomy for tic 
douloureaux that should be mentioned here. In 
almost every operation for trigeminal neuralgia 
in which the ganglion is manipulated, there is 
a postoperative herpes eruption in the segment 
which has been disturbed mechanically. It usual- 
ly is only a minor problem, but can at times be 
very troublesome if ulceration and infection 
occur. 

Frequently, patients will complain of feelings 
of fullness or stuffiness in the ear that tend to 
persist for some time. This problem eventually 
disappears or the patient adjusts to it. 


MARCH, 1973 


227 


Also, occasionally, a peripheral type facial 
palsy will occur, apparently due to traction on 
the greater superficial petrosal nerve during the 
elevation of the dura or, in some cases, the 
ganglion of the seventh nerve itself may be 
exposed and be compressed when the dura is 
elevated. Fortunately, in most cases, this will 
clear eventually, but great care must be taken 
to prevent a keratitis. If the cornea is anesthetic 
as well, a tarsorrhaphy must be performed. 

In addition to these complications, one must 
take care to preserve the motor branch of the 
fifth nerve. Otherwise, there may be malocclu- 
sion and asymmetry of bite. This becomes of 
paramount importance in that small group of 
patients who develop the disease on the opposite 
side of the face and who have suffered a motor 
root injury on the first operated side. 

In the rare case, a persistent uncomfortable 


dysesthesia may occur and prove recalcitrant to 
therapy. 

DR. MEACHAM: This conference today 

certainly gives substance to the fact that there 
are “more ways than one to skin a cat.” I am 
certain we have not exhausted all of the possible 
methods of treating this dreadful disorder, but 
have simply emphasized the most commonly em- 
ployed neurosurgical technics. I think we each 
would agree that the abolition of this painful 
affliction will guarantee a grateful patient. 
However, those unfortunate individuals who 
have atypical facial pain, that is to say, not 
classical tic douloureux, should not be recom- 
mended for any of the procedures outlined here 
for fear of producing a permanent anesthesia 
dolorosa — a condition for which no relief has 
been found and which must be considered 
iatrogenic. 


SAINT ALBANS 

PSYCHIATRIC HOSPITAL 

Radford, Virginia 

STAFF: 

James P. King, M.D. William D. Keck, M.D. 

Morgan E. Scott, M.D. David S. Sprague, M.D. 

Edward E. Cale, M.D. Delano W. Bolter, M.D. 

Terkild Vinding, M.D. 


Clinical Psychology: Administrator 

Thomas C. Camp, Ph.D. ^ 

Carl McGraw, Ph.D. Asst. Administrator 


228 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



CKG 

of Ihc fflofiHi 


HISTORY 

The patient is a 28 year old white woman who 
entered the hospital for evaluation of marked dyspnea 
with minimal exertion. Over the few weeks preceding 
admission, she noted shortness of breath when lying 
flat. A nonproductive cough had been present for two 
weeks. She was started on digitalis with no notable 
improvement in symptoms. 

Physical examination revealed a very lean white 


woman who was slightly tachypneic at rest. Blood 
pressure was 130/78. On examination of the chest, 
scattered basilar rales were present bilaterally. These 
did not clear with coughing or deep breathing. The 
arterial pulses were of normal intensity in all four 
extremities and in the carotid arteries. On palpation 
a left parasternal heave was present. Auscultation 
revealed a very loud first heart sound at the apex. 
A faint grade 1 diastolic rumble was present at the 
apex in the left lateral decubitus position. A grade 
1-2 high pitched diastolic decrescendo murmur was 
present at the left sternal border. There are no systolic 
murmurs present. The remainder of the physical exam 
is unremarkable. The following electrocardiogram was 
obtained. 







■ i 




; r 1 



DISCUSSION 

The patient is noted to have a regular sinus 
rhythm at a rate of 73/min. The P-R interval 
is normal. The QRS forces are oriented nor- 
mally in space and are of normal duration. The 
finding of interest on this electrocardiogram is 
the P wave. It is noted to be unusually broad, 
occupying 0.11 sec of the total P-R duration 

From St. Thomas Hospital, Department of Cardi- 
ology. Nashville. Tenn. 


of 0. 1 6 sec. The normal upper limit of duration 
of P wave in adults above the age of 16 years 
is 0.10 sec. The Macruz criteria for diagnosis 
of atrial enlargement requiring that the ratio 
P/P-R segment be greater than 1.6 is met 
(P = 0.11 sec/P-R segment = 0.05 sec). It 
is noted that the P wave is somewhat slurred 
in upstroke and is asymmetrically skewed to the 
right in lead II. The terminal component of 
the P wave is markedly posterior in the hori- 


MARCH, 1973 


229 


zontal plane causing a deeply inverted P wave 
in V] and Vo. This negative P wave deflection 
(in excess of 0.04 sec duration) is a reliable 
sign of left atrial enlargement except in those 
patients who have chronic obstructive lung dis- 
ease. The tracing, therefore, is presented as 
being representative of many of the classic 
features of left atrial enlargement. It should also 
be noted that there is slight coving of the ST 
segments compatible with digitalis therapy that 
this patient was taking at the time. Right and 
left heart catheterization in this patient revealed 
pulmonary arterial wedge pressures (reflecting 
left atrial pressures) which were only modestly 
elevated in the range of 18 mm Hg mean. The 
“a” wave was 21 with a “v” wave of 19 mm 
Hg. There was a 12 mm Hg resting end 
diastolic gradient across the mitral valve. Mini- 
mal aortic insufficiency was noted angiographi- 
cally. A cardiac series disclosed modest left 
atrial enlargement. 


The electrocardiographic pattern of atrial 
enlargement is felt to be due to an atrial conduc- 
tion disturbance which most commonly accom- 
panies atrial hypertrophy or dilatation. It may 
occur on occasion in the presence of normal 
left atrial pressures and in the absence of de- 
monstrable atrial enlargement roentgenographi- 
cally. In this patient with mitral stenosis of a 
moderate degree the atrial conduction abnormal- 
ity demonstrated on this tracing is most probably 
caused by left atrial enlargement. 

FINAL DIAGNOSIS: 1) Left atrial enlarge- 

ment. 

2) Modest ST segment 
changes compatible 
with digitalis ther- 
apy. 

W. Barton Campbell, M.D. 

Harry L. Page, Jr., M.D. 

Co-Directors 


REFER EYE PATIENTS 

TO AN 

EYE PHYSICIAN 

By so doing, you will be assured of a complete diagnosis of your 
patients’ eyes. 

Guild Opticians complete the cycle for Professional Service. 







BE SAFE-BE SURE 
SEE 

YOUR GUILD OPTICIAN 
FOR 

THE BEST SERVICE 
EYE PHYSICIANS: Please Note- 

Your prescriptions for glasses are "SAFE" when referred to a Guild Optician. 
Bound by the code of Ethics to uphold the highest standards in optical service. 


230 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



The Use of Radioactive 
Xenon Gas in Nuclear Medicine* 

Part I 

Regional Pulmonary Function Studies 

Radioactive Xenon gas has found its way 
into clinical nuclear medicine and its use seems 
to be increasing. Many doctors who have not 
used it but wonder whether they might reason- 
ably do so, must ask themselves the following 
questions: Why use a radioactive gas? Where 
and how should it be used? Are the special 
problems one encounters with its use inordi- 
nately difficult to handle? It is to these questions 
that we address ourselves. 

Although an inert radioactive gas (®“KR) 
was first used in 1955 to assess cerebral blood 
flow and in 1964 ^-^^Xe was first used for this 
same purpose, the use of inert radioactive gas 
for the study of pulmonary function developed 
quite independently. In 1935, Knipping in 
Germany first used inhaled ^•^'^Xenon to study 
regional pulmonary ventilation in patients. This 
excellent work was quickly pursued by doctors 
in Canada and in England who analyzed not 
only the regional distribution of inhaled 
^•^•^Xenon, but also the regional distribution of 
^•^®Xenon following an intravenous injection of 
the gas. Although workers in the United States 
were not active in the investigation of pulmonary 
disease with ^‘^•^Xenon until the mid-1960’s, 
when they entered the field, they utilized the 
scintillation camera and essentially introduced a 
photographic representation of the data. While 
the use of the Anger camera coupled to rate- 
meters resulted in pictures that were admittedly 
only semi-quantitative, it represented an im- 
provement over the data obtained with multiple 
one or two inch probes which, for a variety of 
technical reasons, was never as accurately 
quantitative as was touted by its proponents, 
and certainly was not as readily understood and 
appreciated by clinicians as a photograph. 

The characteristics of Xenon gas that are the 
key to its utility in the study of pulmonary func- 
tion are its marked insolubility in most liquids 

*From the Dept, of Nuclear Medicine, Parkview 
Hospital. Nashville, Tenn. 


(including blood) and its relative inertness. 
Because of these two characteristics, 95% of the 
Xenon dissolved in blood will leave the capil- 
laries and enter the alveolar air spaces during 
the first passage through the lungs. This great 
insolubility of Xenon results in such rapid pas- 
sage of gas from blood to alveoli and thence 
to the exhaled air that the normal biological 
half life of Xenon in man is less than 30 seconds. 
In turn, this short biological half life in man 
markedly reduces the radiation dose to the 
patient. In fact, a patient undergoing a Xenon 
study receives less radiation than with almost 
any other study performed on patients in nuclear 
medicine. 

Xenon is about five times as heavy as air. 
Therefore, if it is to be exhausted to the outside 
after being exhaled by a patient, it should be 
exhausted from a reasonable height so that it 
will diffuse and disperse and not accumulate in 
a dependent area adjacent to the building. For- 
tunately for those nuclear medicine departments 
located underground, commercially suitable 
charcoal traps are now available. Even though 
there is a good deal of Compton scatter in bone 
at the 80 Kev gamma energy peak of ^‘^‘^Xenon, 
this does not present significant problems in 
quantitation of pulmonary function since: 1) 

there are large spaces between the ribs, 2) the 
quantity of isotope in lung is large relative to 
blood and other tissues and it is present for 
an adequate amount of time (30-60 sec.), 3) it 
is not necessary to quantitatively analyze very 
small regions, and 4) one does not need to deal 
with partition coefficients. 

If a patient holds his breath following an 
intravenous injection of Xenon dissolved in 
saline, then the distribution of radioactive Xenon 
gas in alveoli indicates those alveoli which are 
being perfused. If the patient inhales Xenon 
gas mixed with oxygen, the relative activity in 
different regions of the lung during a single 
breath of tidal volume, at functional residual 
capacity, at total lung capacity, during a vital 
capacity measurement, and during washout can 
be evaluated. When these parameters of ventila- 
tion as well as the measurements of regional 
perfusion are related to lung volume, then sig- 


MARCH, 1973 


231 





XENON SCAN 


VENULATION 


PERFUSION 


Washout 




Fig. 2. Centrilobular emphysema — right upper lobe 
(decreased perfusion, decreased ventilation, normal 
volume, delayed washout) 


Fig. 4. Right Pulmonary Artery Atresia (severe re- 
duction of perfusion, slight reduction in ventilation 
and volume) 

good knowledge of pulmonary function. 

In many ^-^-^Xenon perfusion-ventilation 
studies, the simple qualitative evaluation of the 
pattern of distribution of ventilation and per- 
fusion relative to volume is characteristic if not 
pathogonomonic of specific disease entities. 
Pulmonary embolus (fig. 1), centrilobular 
emphysema (fig. 2), hereditary pan-lobular 
emphysema (fig. 3), and pulmonary artery 
atresia (fig. 4) are examples of this. In cases 
of carcinoma of the lung a disproportionate 
reduction of perfusion relative to volume and 
ventilation in the region of the malignancy may 
ominously predict the unresectability of the 
tumor. A Xenon study on patients with hypoxia 
will occasionally interdict surgery, will occa- 
sionally add an indication for surgery, and will 
almost always lead to a more rational approach 
to the therapy of lung disease. 

Robert L. Bell, M.D. 

Director 


Fig. 3. Hereditary Pan Lobular Emphysema (upward 
shift of perfusion and ventilation, delayed washout at 
both bases) 

nificant imbalances of perfusion and ventilation 
can be appreciated. 

Since regional imbalance of perfusion and 
ventilation are very common and are the main 
cause of hypoxemia, these are probably the 
most important parameters of pulmonary func- 
tion that can be measured. If these studies are 
performed on a patient in the upright position, 
then the gradient of perfusion from the bottom 
of the lung to the top of the lung can be used 
to evaluate pulmonary vascular pressure (partic- 
ularly if it is elevated). If one carefully eval- 
uates the washout of Xenon after perfusion and 
after ventilation, then regionally increased air- 
ways resistance can be appreciated. The equip- 
ment that is needed to perform these studies is 
an Anger camera, diverging collimator, closed 
spirometer system equipped with a large bell, 
COo trap, oxygen supply, circulating fan, strip 
chart recorder, and an exhaust system. Most 
important of all, the physician responsible for 
the performance of these tests should have a 


Fig. 1. Pulmonary embolus — right lower lobe (de- 
creased perfusion; normal ventilation and volume) 






■ : . , iimf 

;S: w- li 




232 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 





kiboNilofii fflcdkinc 




The Clinical Usefulness 
Of Isoenzyme Determinations* 

Since the recognition of lactate dehydro- 
genase (LDH) isoenzymes in 1957, much work 
in this subspecialized field of diagnostic enzy- 
mology has taken place. Although the LDH 
isoenzymes remain the most completely studied 
and the best understood as regards their cor- 
relation with clinical disease states, close to 
thirty other enzymes have been investigated in 
this regard, only a few of which may be helpful 
in diagnosis at this time. Isoenzymes of a par- 
ticular “parent” enzyme are separated by elec- 
trophoresis. and numbered in sequence, starting 
with the fastest-migrating (anodal) fraction. 
The relatively restricted organ or tissue 
specificity of the various isoenzyme fractions, 
compared with that of the total serum enzyme 
activity, enhance the diagnostic value of labora- 
tory enzyme tests. 

The most commonly encountered LDH 
isoenzyme patterns are widely familiar today. 
The fastest-moving (LDHi and LDH2) fractions 
predominate in myocardium, erythrocytes, and 
renal cortex, and thus typically increase in serum 
with destructive processes involving those 
organs (e.g.. myocardial infarction, hemolysis, 
and renal infarction). A prominent rise in 
LDHi may be detected within a few hours fol- 
lowing myocardial infarction, making this a 
diagnostically sensitive test. Hemolysis, partic- 
ularly in the megaloblastic anemias, generally 
results in LDHi and LDH 2 elevations, often of 
very great magnitude. Paradoxically, in various 
chronic renal diseases the elevation occurs in 
the LDH5 fraction, suggesting its origin from 
the renal medulla, rather than the cortex. The 
high total LDH in malignant diseases generally 
results from elevations in LDH2, LDH3, and 
LDH4; occasionally only an isolated high LDH3 
is seen — an ominous laboratory finding. High 
tissue levels of LDH4 and LDH5 in skeletal 
muscle and liver result in the serum elevations 
of these fractions as seen in skeletomuscular 
trauma and acute hepatitis. Multiple fraction 


*From the Laboratory Service, Methodist Hospital, 
Memphis, Tenn. 38104. 


elevations are perhaps the most commonly en- 
countered pattern, and suggest damage to 
several organ systems, such as seen in shock, 
widespread malignancy, and congestive heart 
failure following myocardial infarction. Occa- 
sionally “aberrant” isoenzyme bands are en- 
countered in malignant diseases, and various 
gonadal malignancies have reportedly mimicked 
a classical myocardial infarction pattern. 

Alkaline phosphatase isoenzymes have proved 
rather disappointing diagnostically, due largely 
to major technical difficulties in their separa- 
tion and identification. While still predominantly 
useful in research, electrophoretic analysis com- 
bined with certain physiochemical procedures 
may be of value in clinical laboratory diagnosis. 
Four major tissue components comprise most of 
the total serum activity — hepatobiliary, skeletal, 
intestinal, and occasionally, placental. The first 
two, diagnostically the most important, are un- 
fortunately poorly separated by electrophoresis, 
which accounts for much of the confusion in 
pattern interpretation. By considering other 
parameters of hepatic function (for example, 
the gammaglutamyl transpeptidase, which is 
frequently elevated in obstructive hepatobiliary 
disease but rarely affected by osseous skeletal 
disorders), one increases the diagnostic useful- 
ness of alkaline phosphatase isoenzyme separa- 
tion. 

Total creatinine phosphokinase (CPK) levels 
are an early, sensitive indicator of myocardial 
damage, but may also indicate other types of 
tissue damage (e.g., skeletal muscle injury). 
Three major tissue isoenzyme bands of CPK 
have now been identified — brain, heart, and 
skeletal muscle. However, there is some electro- 
phoretic similarity in the last two fractions, and 
as yet this type of analysis has not improved 
upon the diagnostic specificity or sensitivity of 
the simple total CPK determination. It has 
occasionally been useful in identifying the source 
of the elevated serum fractions in various dis- 
orders such as hypothyroidism (myocardial and 
skeletal muscle) and cerebral injury (brain 
fraction and/or skeletal muscle). 

Few other isoenzyme analyses have significant 
diagnostic value at this time. The SCOT has 


MARCH, 1973 


233 


been found to consist of two isoenzyme frac- 
tions, while SGPT apparently exists only in a 
single active form. Separation of salivary and 
pancreatic amylase isoenzymes may eventually 
be helpful in determining the tissue origin of an 
elevated total serum amylase, and leucine 
aminopeptidase has been similarly studied in 
attempts to distinguish between intrahepatic and 
extrahepatic disorders. The simple biochemical 
methods for distinguishing between prostatic 


and non-prostatic acid phosphatase have so far 
largely negated the value of determination of 
serum acid phosphatase isoenzymes. Isoenzymes 
of aldolase, isocitrate dehydrogenase, malate 
dehydrogenase, cholinesterase, and gamma- 
glutamyl transpeptidase have been identified, and 
may in the future be of value in clinical labora- 
tory diagnosis. 

Dean G. Taylor, M.D. 



ffom Ihe lenne//ce clepciflincnl 
of menicil hecillh 



The Physician’s Assistant 
In a Psychiatric Hospital 

Nurses and aides trained to assist psychia- 
trists in the care of the mentally ill have been 
recognized for some years and their role is 
quite well-established. They along with 
psychiatrists, social workers, and others con- 
stitute the treatment team which assumes re- 
sponsibility for newly-admitted patients. 

For the acutely ill, the teams categorize 
patients, establish therapeutic regimens, both 
psychiatric and pharmaceutical, with the objec- 
tive of discharging the majority to their home 
community, under the care of either a family 
physician or a mental health clinic. A high rate 
of discharge is attained for the acutely ill in 
all age groups. The psychiatric team obtains 
less definitive results in a second category of 
patients — those who relapse after treatment, or 
suffer from such degree of mental disease that 
they ultimately need to spend many months, if 
not the remainder of their life, in a mental 
institution, psychotic behavior controlled by 
psychotropic drugs. Among these are patients 
who have schizophrenia, severe degrees of 
manic-depressive disease, mental retardation, or 
chronic brain syndrome of whatever cause. The 
psychiatric team manages these patients to the 
point of controlled living in an institution. 

Finally, there is a portion of the population 
in the hospital for the mentally ill whose chronic 
disease often is more physical than mental or of 
about equal proportion. These patients are dis- 

234 


abled partially or completely by chronic brain 
syndrome — of whatever cause, by cerebral vas- 
cular disease, or seizures of many years duration. 
These as well as the chronically ill patients 
having schizophrenia, manic-depressive disease, 
or who are mentally deficient will, as they grow 
old in the institution, become subject to “heart 
disease, stroke, and cancer” as any other 
portions of the aging population. Whereas, non- 
psychotic persons are admitted to community 
hospitals for episodic treatment, to be followed 
at home or in the doctor’s office, patients in 
mental institutions need episodic management 
and continued follow-up care within the institu- 
tion in most instances — actually nursing home 
care. Additionally, there are numbers of 
patients having neurologic disabilities without 
mental disease who end up in these hospitals 
because there is no other place for them, for 
example those who have residua of strokes, 
Huntington’s chorea, parkinsonism, and the like. 

It is this third category of patients to which 
this discussion is directed. They divert the 
energies and activities of the psychiatric team 
from their primary function of treating the 
mentally ill, to supervise routine nursing care 
and to direct medical, surgical, or rehabilitative 
management of these patients, more physically 
ill than mentally ill. Psychiatric effectiveness is 
diluted thereby. 

Few today argue with the concept that there 
is a shortage of physician manpower which will 
become enhanced with universal health care, as 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


demands for elective medical care expand. Ad- 
ditionally, it is no secret that psychiatric and 
medical care in state-supported institutions for 
the mentally ill is only occasionally ideal. The 
National Observer aired this topic as a front- 
page story recently (December 2, 1972). A 
couple of years ago in this Journal, Goshen^ re- 
viewed the historical developments which ac- 
count for a lower level of quality in patient 
care in state hospitals and the current trends 
in treatment of the mentally ill. 

It is a foregone conclusion that, given a form 
of universal health care which will be with us 
shortly, governmental surveillance for quality 
ultimately will include the state hospitals, as 
already spelled out for the private practice of 
medicine. The dilution of psychiatric treatment 
by the burden of providing care for the chroni- 
cally ill will not be countenanced. 

All this leads to the physician’s assistant who 
could accept much responsibility in our public 
institutions, psychiatric or other. Even govern- 
ment approves (under Medicare) as little as 
one visit by a physician to his patient in a 
nursing home per month. (An interesting con- 
tretemps are attempts by payors for government 
to refuse allowance of more than one visit for 
episodic disease, say of pneumonia, by the phy- 
sician attending a patient in a nursing home.) 
A physician’s assistant, and especially a nurse, 
with a certain amount of postgraduate educa- 
tion and training will be able to provide better 
care for the chronically ill than a physician. 
This is said advisedly since she has the basic 
“know-how” of making a patient comfortable. 
She readily may be educated to recognize basic 
symptoms and signs and to the use of a limited 
number of laboratory and other technical exami- 
nations for the “99 %” of the clinical problems 
met in a nursing home environment. Similarly, 
she may be taught the therapeutic armamentari- 
um essential to such a group of patients, even 
though the ultimate responsibility will need to 
rest on the shoulders of the visiting physician. 

This statement of the potential of a nurse 
physician’s assistant is based upon a limited 
experience on a 60-bed infirmary at Central 
State Psychiatric Hospital. I believe this can 
confirm an established and on-going experiment 
for a decade of the nurse as a practitioner in 
ambulant chronic disease care as established in 
Memphis. Dr. John W. Runyan, Director of 
Health Care Delivery, University of Tennessee 
College of Medicine, has developed such a sys- 


tem based upon the City of Memphis Hospital 
and the Shelby County Health Department.- 
Some 85% of these patients fall into three cate- 
gories, — diabetes mellitus, cardiac and hyper- 
tensive disease. Dr. Runyan has gradually ex- 
tended the diagnostic and therapeutic training 
for the public health nurses in that program as 
the proof of nurses’ competence has become 
established. 

Much has been written upon the topic of 
the physician’s assistants since the inception of 
the program at Duke University Medical Center 
in 1965. In an editorial in this journal two 
years ago, I reviewed the thinking by the medical 
and legal professions and medical organizations 
as of that time.^ It has not changed much since 
then. In that editorial, I ended with the state- 
ment that, “I believe a specially trained nurse 
in consultation with a doctor, could manage 
the medical problems in private or public insti- 
tutions, equally well or in some respects even 
better than a physician making hurried rounds.” 
I contend that a nurse physician assistant may 
assume responsibility for the major portion of 
the management of the chronically ill patient 
with the advice and consultation of the “round- 
ing” consultant periodically, be he psychiatrist 
or part-time internist or family physician. There 
will need to be a solution to this problem of 
the chronically ill in the accredited psychiatric 
hospital so the psychiatrist may fulfil his re- 
sponsibilities without the burden of caring for 
the patient who is in need only of custodial care 
whether for mental or physical disability. 

In meeting the argument that nurse manpower 
shortage should not be aggravated further by 
the development of a cadre of nurse practition- 
ers, at least a partial answer lies in an attempt 
to attract some of the 280,000 inactive nurses 
of this country back into a productive medical 
life, after children are grown, and into a new 
area which may be carried out on the basis of 
a daytime shift. 

R. H. Kampmeier, M.D. 

Medical Director, Central State 
Psychiatric Hospital, Nashville 

REFERENCES 

1. Goshen, Charles E: Old and new trends in com- 
munity health, J T M A 64:29-35, 1971. 

2. Runyan, Jr., John W: The public health nurse 
as a practitioner in chronic disease care. South Med 
60:15-19, 1972. 

3. Editorial: Physicians’ assistants, J T M A 64:56- 
57, 1971. 


MARCH, 1973 


235 



The Cooper Quiz* 

(Answers found beginning on page 292) 

Answer true or false unless otherwise indicated 

1. A careful follow-up should be done on all patients having halothane anesthesia. Evidence 
of liver toxicity does not contraindicate its further use after complete recovery from the 
toxicity. 

2. Strontium 87m is an accurate scanning agent in children suspected of infection in either 
bones or joints. 

3. Echocardiography is relatively specific for right ventricular overload secondary to atrial 
septal defects. 

4. In reality echocardiography is a good screening test but not specific enough to differentiate 
all the defects that produce right ventricular overload. 

5. Laryngeal cancer is about equally divided between men and women who have the same 
smoking patterns. 

6. A nonfunctioning thyroid nodule in men should be treated surgically. 

7. Separating catheter-associated urinary tract infection patients from non-infected patients 
does nothing to decrease the risk of infection. 

S. Oral contraceptives may affect Bio and folate metabolism and produce a megaloblastic 
anemia. 

9. When women taking oral contraceptives have a low Bio serum concentration, oral adminis- 
tration of folate will correct the deficiency. 

10. Patients with hepatic cirrhosis who have ascitic fluid with a high protein content have sig- 
nificant impairment of portal blood flow to the liver. 

11. The 25 year record of health and safety of atomic energy programs in the U.S. is (good) 
(poor). 

12. There is some evidence that dexamethasone may produce cardiac arrhythmias where 
methylprednisolone sodium succinate is much less apt to. 

13. A study done in Boston City Hospital indicates a 26 to 32 per cent error in cancer 
diagnosis. That is missed diagnosis. 

14. The measurement of serum thyroxine as an indicator of the total hormone present is de- 
pendent on the protein bound portion of thyroxine. 

15. Patent ductus arterosus occurring in premature infants increases in incidence with increas- 
ing prematurity. 


* Published monthly by the Dept, of Medical Education, the Cooper Hospital, Camden, N.J., William 
T. Snagg, M.D., Director. 


236 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


16. Patent ductus arteriosus in premature infants should not be treated surgically until after 
the first year of life. 

17. Kidney patients on long-term dialysis are frequently hypoalbuminemic. Getting the blood 
albumin up to normal is not possible with high protein feeding but requires additional 
human albumin I.V. 

18. Thiabendazole is effective in the treatment of both ascaris strongyloides and trichinella. 

19. Patients with nontoxic goiter should be given iodine in relatively large doses. 

20. Ouabain does improve left ventricular function in patients with acute myocardial infarct. 

21. Bacterial concentrations exceeding a certain number of colonies per ml of urine are in- 
dicative that the infection is renal rather than lower urinary tract. 

22. Reversible nonobstructive hydronephrosis does not occur without urinary-tract infection. 

23. There is not even suggestive evidence that stilbesterol therapy causes endometrial carcinoma. 

24. Headache and epistaxis are probably not more frequent in hypertensive patients than per- 
sons without hypertension. 

25. There is evidence that if chloramphenicol is to be used in the therapy of H. influenzae 
meningitis, it should be given I.M., not orally. 

26. There is a season influence on serum urate levels and even artificial sunlight can cause 
elevations. 

27. One of the characteristics of the anemia of “chronic disorders” is an increase in bone 
marrow iron. 

28. In the anemia of “chronic disorders” the reduction of albumin and transferrin is not re- 
lated to the severity of the anemia. 

29. Physical exercise, jogging one mile in 10 minutes, resulted in significantly reduced blood 
cholesterol levels. 

30. Monitoring left ventricular filling pressure in patients with myocaridal infarction is a use- 
ful endeavor. Keeping the filling pressure around 18 to 22 mm of Hg is about ideal. 

31. In a long-term study of 150 patients with permanent ventricular pacemakers, it was inter- 
esting to note that those implanted before 1964 had a better survival rate than those after 
1964. 

32. Of the 26 patients with permanent pacemakers who developed congestive failure. 50 
percent had a disease that was perdisposing to failure. 

33. You may assure patients that permanent pacing does not involve risks of mortality or mor- 
bidity appreciatively greater than the normal population. 

34. Patients with diabetic neuropathy lose their capacity for marked digital vasoconstriction. 

35. Keflin may be nephrotoxic and produce RBC abnormalities, but it does not affect blood 
platelets. 

36. After treatment of hyperthyroidism and the production of euthyroidism, recurrent hyper- 
thyroidism is not rare. T 3 elevation may be the only increased iodoaminocid. 


MARCH, 1973 


237 


Just what do you get for 
your AMA dues? 


You get a package of personal and professional 
services and benefits you’ve probably never 
been fully aware of. 

You get insurance programs at a cost consider- 
ably lower than those purchased on an individ- 
ual basis. A $250,000 Excess Major Medical 
Policy. Group Life. Disability Income Insurance. 
Professional Liability Insurance (in co-sponsor- 
ship with your state society.) Then there’s the 
AMA Members Retirement Fund. 

You get a comprehensive medical library to 
help you do your research. An editing service 
for your articles. Information and reports on 


medical and health subjects from any AMA 
department. 

You get publications to keep you abreast of 
medical and health developments. JAMA. 
American Medical News. And Prism, the new 
socioeconomic journal. 

You get the Physician’s Placement Service to 
help you find a place to practice or locate an 
associate. And if you’re a resident winding up 
your training, there’s a special workshop to help 
prepare you for setting up your practice. 

All these are just a few of a broad spectrum of 
benefits and services you get for your dues. But 
even more important, you get a strong and effec- 
tive national spokesman to represent you, your 
interests and your views. 

Join us. 

We can do much more together. 

American Medical Association 
535 N. Dearborn St./Chicago, III. 60610 



ANNUAL MEETING NEXT MONTH TO BE ONE OF BEST . . . Memphis, April 11-14, 
will have something interesting and informative for every doctor. 

Plan to attend and participate. THE ANNUAL MEETING PROGRAM IS PUBLISHED 
IN A SPECIAL COLORED SECTION IN THIS ISSUE OF THE J O URNAL . . . Note 
the important speakers on topics that affect every physician . • . 

And the many scientific and special events with outstanding speakers 
both on the general program and through the medical specialty societies 
. • . Note, too, the excellent entertainment at the President's 
Banquet, plus the dance to follow for your social events . . . This 
has to be one of the best, most outstanding, AND IMPORTANT, meetings 
ever sponsored in the history of the Association • . • Don't miss it ! 

POSTING RULES DROPPED . . . Price schedules and signs are no longer 
required in the physicians' offices or in health care facilities. 

These have been removed with the changes made by the Price Commission. 
Phase III regulations recently published, continue wage and price con- 
trols on the health services industry, but revoked the Phase II regula- 
tions that required physicians and health institutions to provide an 
inspection schedule of charges for principal services, and to post 
a sign giving the schedule of charges. 

kXi. 

MAJOR HIGHLIGHTS OF JANUARY TMA BOARD MEETING 

THIRTY-EIGHT ITEMS OF BUSINESS ACTED UPON BY THE BOARD ... The Trustees 
held the quarterly meeting in Nashville on January 13-14 . . . And 
appointed a Nominating Committee from the certified and ex-officio dele- 
gates from county societies. The Nominating Committee consists of 
nine physicians from the three grand divisions of the state to submit a 
slate of officers to be voted upon by the House of Delegates . . . 

The Board nominated three Tennessee physicians to receive the Distin- 
guished Service Award; appointed one new director to serve on the 
Education and Research Foundation for Health Careers; appointed a 
physician to fill the vacancy on Medical Political Action body— IMPACT 
. . . And appointed, or reappointed, nearly 200 physicians to comprise 
the members of the Standing and Special Committees of the Association, 
these appointments to be confirmed at the April Board meeting at which 
time they will become effective. 

3|C 5|C ^ .j. 

BOARD MEETINGS TO BE INCREASED.. . . Due to the heavy schedule of work 
and increased activities of TMA, instead of conducting quarterly 
meetings, the Board will hold regular meetings on the second Sunday 
in the even numbered months of the year. This will increase meetings 
of the Board from four to six yearly. 


CERTIFICATE OF NEED LEGISLATION-AND COMPREHENSIVE HEALTH PLANNING . . . 

In further study on the issue of Certificate of Need legislation, the 
Board reaffirmed its position that TMA would favor Certificate of Need 
only where it pertains to in-patient hospital beds, acting further 
to convey this information to the Commissioner of Public Health . . • 

The Board went on record favoring that Comprehensive Health Planning 
remain under the State Public Health Department, and that Certificate of 
Need authority be placed within the Health Department, under the Hos- 
pital Licensing Board* 

❖ ^ ^ ^ ❖ 

PHYSICIAN'S ASSISTANT LEGISLATION . . • The Board studied a proposed 
Physician's Assistant bill prior to adopting a motion that the proposed 
bill be approved and forwarded to the TMA Legislation Committee for 
sponsorship in the General Assembly . . • Also, final approval was given 
to the Emergency Medical Technicians legislation, as amended, and 
referred this matter to the legislative Committee to be submitted in the 
General Assembly. 

^ 

T* ^ ^ O'* "f* 

TMA RESOLUTIONS TO BE SPONSORED IN THE HOUSE . . . Four resolutions were 
adopted for introduction in the House of Delegates. These included an 
informative resolution on Professional Standards Review Organizations 
(PSRO's) ; a resolution concerning difficulty with the Aetna Life 
and Casualty Insurance Company; a resolution on "Statement of Under- 
standing,” and another on utilization and peer review policy . . • The 
Board made several recommendations for clarification in the TMA 
Constitution and By-Laws and requested the Committee on Constitution 
and By-Laws to submit amendments for the House's consideration in April. 

^ S.I0 

^ ‘T* "f* 'T* 'T* 

OTHER IMPORTANT ACTIONS • . . The Board authorized sponsoring an eight- 
day Hawaiian adventure in March, 1973. This is in addition to the 
planned August tour to Scandinavia . . . Studied in depth guidelines 
concerning unlicensed physicians in Tennessee, two resolutions being 
submitted to the House by the TMA Judicial Council on this subject . . • 
Voted to support legislation wherein inspection of restaurants legisla- 
tion should be under the direction of the Department of Public Health 
rather than that of Conservation . . . Heard a report on physician's 
union . • • Discussed the AMA National Leadership Conference and desig- 
nated members of the Board to attend, this conference held February 
16-18 in Chicago • . • Received a report of conflicting problems with 
physicians in Lawrence County with the County Health Department . . . 
Designated Dr. John Duckworth to represent the Board at the three-day 
March meeting of the Foundation for Medical Care Conference in Memphis 
• . . Studied the matter of Student Education Fund recipients defaulting 
on payments when student loans are due . . . Approved a program and 
materials to be used in TMA's stepped up physician recruitment program 
. • . Approved a uterine cancer task force program sponsored by the Ten- 
nessee Division of the American Cancer Society. 

vt. OL# 

^ ^ ^ •■f* 

PRIMARY HEALTH CARE CENTERS • . . The Board studied in considerable 
detail the material presented pertaining to experimental Primary Health 
Care Centers in the state. One or two such programs are already 
funded as an experiment. This topic was given considerable discussion. 
The Board acted to the extent that where a demonstrated need exists 
for a Primary Health Care Center, that the approval of the medical 
society that included the area be obtained. 



TMA TO EXPAND PHYSICIAN PLACEMENT SERVICE ... In an effort to retain 
more Tennessee trained MDs upon completion of their medical education, 
TMA's Placement Service has embarked upon a new recruitment endeavor. 

A concentrated and continuing effort will be made by TMA to keep 
residents and interns informed of the many practice opportunities avail- 
able across Tennessee. By so doing, it is hoped that an increased 
number will choose to establish their practice in the State. As a means 
of communicating with residents and interns, TMA will periodically 
distribute a 4-color, 8-page brochure specifically designed to outline 
the many reasons why Tennessee is a good place to practice medicine. 
Included with the brochure will be a current sampling of practice 
locations available. These specific practice locations will be taken 
from those on file with the TMA Placement Service. Communities and/or 
TMA members who are in need of physicians are urged to contact TMA and 
to list their practice opportunity with the Placement Service. Hospital 
Administrators in the seventeen Tennessee institutions in which resi- 
dency and internship programs are carried out have agreed to assist TMA 
in distributing the brochure and accompanying practice opportunity 
locations to the more than 950 MDs currently participating in their 
training programs. 


FEDERAL JUDGE RULES TENNESSEE ABORTION LAW INVALID . . . U.S. District 
Judge L. Clure Morton has declared Tennessee's 1883 anti-abortion 
statute unconstitutional. Judge Morton based his ruling on a recent 
U.S. Supreme Court decision in cases from Texas and Georgia which 
he said left no doubt that the State's law was invalid. Judge Morton 
permanently enjoined State Attorney General David M. Pack from the 
enforcement, operation and execution of the statutes involved. TMA 
President, William T. Satterfield, Sr., M.D. of Memphis, immediately 
appointed a Special Ad Hoc Committee to study the court's decision and 
its effect on Tennessee law and to make recommendations regarding Abor- 
tions in Tennessee in light of the court's ruling. Dr. C. Gordon 
Peerman, Jr. of Nashville, chairman of the TMA Board of Trustees, was 
designated chairman of the Special Committee. Also appointed were Drs. 
Russell T. Birmingham of Nashville, Anne U. Bolner of Fayetteville, 
Stewart A. Fish of Memphis, Eugene W. Gadberry of Memphis, W. Powell 
Hutcherson of Chattanooga, Sam P. Patterson of Memphis and John 
H. Saffold of Knoxville. 


TENNESSEE PHYSICIANS ATTEND AMA LEADERSHIP CONFERENCE ... A sizable 
delegation of TMA members attended the first AMA National Leadership 
Conference held in Chicago, February 16-18. The purpose of the meeting 
was to provide interested physicians with the opportunity to develop 
new leadership skills, a better understanding of issues of particular 
interest to medicine, to review and discuss the many challenges con- 
fronting the medical profession in the year ahead and to formulate 
programs and strategies. Nine seminars were presented during the course 
of the meeting including one regarding PSRO (Professional Standards 
Review Organizations) and other aspects of H.R. 1, adopted by Congress 
last year. Tennesseans in attendance were Drs. William T. Satterfield, 
Sr., 0. Morse Kochtitzky, J. Kelley Avery, E. Kent Carter, Tom E. 
Nesbitt, C. Gordon Peerman, Jr., George W. Holcomb, Jr., Olin Williams, 
T. K. Ballard, and Charles H. Alper ; Flo Richardson, Les Adams and 
Hadley Williams were Medical Society Executives in attendance. 


^ ^ ^ ^ jjj 


STATUS OF THE NATIONAL HEALTH SERVICE CORPS IN TENNESSEE . . . Informa- 
tion from the Department of Public Health indicates that 11 Tennessee 
communities have received approval for physician assistance under NHSC 
(National Health Service Corps). Of the 11, physicians have located and 
begun practice in three areas. Daniel Bibleheimer, M.D. has been 
assigned to Adamsville (McNairy County), Dennis A. Savoi, M.D. has been 
assigned to Decatur (Parsons and Decatur County) and William R. Kenny, 
M.D. has been assigned to Surgoinsville (Hawkins County). Four other 
MDs have accepted assignments and will begin practice in July, 1973 in 
the following communities: Jamestown (Fentress County), Kingston (Roane 
County), Spring City (Rhea County) and Surgoinsville. In addition, 
two dentists have been assigned and have begun practice under the pro- 
gram. They are: Robert Abraham, D.D.S. in Celina (Clay County) and 
William Hendon, D.D.S. in Rutledge (Grainger County). The communities 
of Linden (Perry County) , Lynchburg (Moore County) , Monterey (Putnam 
County) and Wartburg (Morgan County) have been approved but no phy- 
sicians have been assigned as yet. 


^ ^ 


TMA TO SPONSOR SCANDINAVIAN TOUR IN AUGUST ... A 14-day, three- 
country Scandinavian tour for TMA members and their families has been 
announced and will depart Nashville and Memphis August 3, 1973. 

The tour program, begun by TMA in 1970, has been well received by those 
who have taken advantage of the savings involved in group travel. The 
four countries and cities to be visited are Stockholm, Sweden; Helsinki, 
Finland and Copenhagen, Denmark. The tour price includes everything— 
chartered air transportation by private 707 jet, deluxe hotels, 
breakfasts at the hotel each morning and gourmet dinners at a choice 
of the finest restaurants each evening. All tips, transfers and other 
extras are taken care of for the traveler. Short side trips will be 
offered to Leningrad, Russia and to Oslo, Norway. Interested members 
are urged to forward their reservations immediately since they are 
processed on a first-come basis. Over 170 TMA members and their 
families have just returned from a one-week TMA sponsored trip to 
Hawaii. 



ARE YOU ALL SET? 

138th Annual Meeting 
April 11-14, 1973 

Memphis 


Special Section 

SCIENTIFIC PROGRAM 
OF THE 138TH ANNUAL MEETING 
OF THE 

TENNESSEE MEDICAL 
ASSOCIATION 

General Information 

The oflBcial program contains detailed informa- 
tion on the 1973 annual meeting of the Tennessee 
Medical Association, conducted in Memphis, Ten- 
nessee, April 11-12-13-14, 1973. 

4 Registration 

The registration desk will be located in the 
Sheraton-Peabody Hotel Lobby. All members, 
visiting speakers, interns, residents, exhibitors, and 
guests are urged to register. Admission to all 
meetings and sessions, and to the exhibits is by a 
badge obtained at the registration desk. THERE 
IS NO REGISTRATION FEE. 

Programs for all activities during the Annual 
Meeting are available at the registration desk. 
Those eligible to register are: Members of the 
Tennessee Medical Association; physicians from 
other states who are members of their respective 
state medical associations; residents, interns, med- 
ical students and guests. 

4 Registration Hours 

(All times are Central 
Standard Time) 

Wednesday, April 11, 10:00 A.M. 

(Special registration for mem- 
bers of the House of Delegates 
from 10:00 A.M. to 5:00 P.M.) 
(Advance registration for ex- 
hibitors and early arrivals 
after 4:00 P.M.) 

Thursday, April 12 8:00 A.M. to 5:00 P.M. 

Friday, April 13 8:00 A.M. to 5:00 P.M. 

Saturday, April 14 8:00 A.M. to 1:30 P.M. 

4 Annual Meeting Headquarters 

Headquarters are located in the Sheraton- 
Peabody Hotel, Memphis, where many activities 
are scheduled. The specialty societies will conduct 
their meetings concurrently with TMA in Memphis. 
These and other activities will be conducted in the 
Sheraton-Peabody Hotel and the Downtowner 
Motor Inn. Any locations where specialty so- 
cieties are meeting outside of the Sheraton- 
Peabody or the Downtowner are listed in this 
program under the “Days” that the societies are 
scheduled to meet. The Woman’s Auxiliary ac- 
tivities will be conducted entirely in the Albert 
Pick Motor Inn. 


4 TMA Headquarters Offices 

The TMA headquarters offices will be located 
during the meeting in the Sheraton-Peabody in 
Rooms, 302-306-310-315. The rooms where the 
offices are located will be easily identified by 
signs. 

A member of the staff will be available to 
assist you at aU times. Members of the House of 
Delegates, Officers, and Reference Committee 
Chairmen can obtain secretarial help when needed. 
Your headquarters office staff is available to assist 
you in your needs. 

J. E. Ballentine, Executive Director 
L. Hadley Williams, Assistant Executive Di- 
rector 

Don Alexander, Executive Assistant and 
Field Representative 

William V. Wallace, Executive Assistant 
John R. Coles, Executive Assistant, Legisla- 
tion 

Miss Linda Bass, Administrative Secretary 
Mrs. Carolyn Sandlin, Records and Book- 
keeping 

Mrs. Janice Hargis, Secretary 
Mrs. Judy Poe, Secretary 
Miss Judy Smith, Secretary 

4 President’s Reception and Banquet 

The President’s Banquet will be preceded by 
the President’s Reception, sponsored by the Ten- 
nessee Medical Association, and beginning at 6:00 
P.M. on Friday evening, April 13, in the Sheraton- 
Peabody Hotel. 

The BANQUET will follow at 7:00 P.M. in 
the Ballroom. TICKETS ARE AVAILABLE AT 
THE REGISTRATION DESK. A limited number 
can be accommodated. GET YOUR TICKETS 
EARLY. 

4 Communications — 

Emergency Telephones 
Memphis 525-8445 and 525-8446 
( Area Code 901 ) 

A blackboard will be placed in a conspicuous 
location on the mezzanine floor in the Sheraton- 
Peabody Hotel where doctors’ calls will be listed. 
PLEASE CHECK OFTEN WITH THE LIST- 
INGS ON THE CALL BOARD. The emergency 
telephones will be on the mezzanine floor of the 
Sheraton-Peabody, near the exhibit tarea. 

4 Specialty Society Luncheon Tickets 

Tickets to specialty society banquets and 
limcheons, as well as the Woman’s Auxiliary af- 
fairs, can be obtained from Specialty Societies 
respective registration desks. PURCHASE YOUR 
TICKETS AT THE TIME OF REGISTRATION. 
The number that can be accommodated is limited. 

4 House of Delegates 

The first session of the House of Delegates 
will be convened on Wednesday afternoon, April 


248 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


II, beginning at 4:00 P.M. in the Sheraton- 
Peabody. The second session will be held on 
Saturday, April 14, beginning at 9:00 A.M. in the 
Sheraton-Peabody. Reference Committees will 
meet on Thursday, April 12, and the locations of 
the Reference Committee rooms are hsted below. 
Any TMA member may appear before a Reference 
Committee to testify on the business before the 
House of Delegates. 

♦ Reference Committee Meeting 
Rooms — House of Delegates 

Reference Committee on Constitution 


and By-Laws Room 202 

Reference Committee (A) Room 215 

Reference Committee (B) Room 213 

Reference Committee (C) Arkansas Room 

345-351 


Reference Committee (D) ..Mississippi Room 

339-343 

(The Reference Committee on Outstanding 
Physician of the Year will meet in the TMA offices 
on Wednesday.) 

Reference Committees wiU conduct their hear- 
ings beginning at 9:00 A.M. on Thursday, April 
12 . 

♦ General Meetings — TMA 

The general presentations at the 138th TMA 
annual meeting will be presented on Friday morn- 
ing, April 13. (See complete program under the 
“Days” as listed herein.) The specialty societies 
meeting concurrently with the Tennessee Medical 
Association will conduct their scientific and busi- 
ness programs on April 12, 13 and 14. Please note 
the program listing the scientific meetings of all 
specialty societies each day. Every member regis- 
tered is welcome to attend any scientific meeting 
of the specialty societies. Of special interest will 
be the presentations of general interest by guest 
speakers on Thursday, Friday and Saturday, April 
12-14. Please note topics and outstanding speak- 
ers listed in this program. 

♦ Specialty Societies 

Sixteen specialty societies will be conducting 
their meetings concurrently with the Tennessee 
Medical Association in Memphis. Scientific and 
business sessions of the specialty societies will be 
held on April 12-13-14. SEE DETAILS IN THIS 
PROGRAM LISTED UNDER EACH OF THE 
ABOVE DATES AND UNDER “ANNOUNCE- 
MENTS.” 

♦ Woman’s Auxiliary 

The TMA Woman’s Auxiliary will conduct all 
sessions of its annual meeting at the Albert Pick 
Motor Inn, Memphis. The registration desk of the 
Auxiliary will be located in the Albert Pick Motor 
Inn, and all committee meetings, board meetings, 
and general sessions will be conducted in the 
designated rooms at the Albert Pick Motor Inn. 


♦ Exhibit Attendance Prize 

To encourage greater physician participation in 
the technical exhibits, the exhibit committee con- 
tinues a feature for 1973. TMA will give away to 
a lucky physician, a Portable Color Television, as 
a Exhibit Attendance Prize. To qualify, each regis- 
tered physician is required to visit a minimum 
of thiity technical exhibitors. The drawing will 
be held Saturday (April 14) afternoon at 1:00 
P.M. in the exhibit area. Instructions for par- 
ticipating wiU be given each physician at the time 
of registration. 

♦ Scientific Exhibits 

Physicians desiring to present scientific ex- 
hibits will locate these in tlie exhibit area of the 
Sheraton-Peabody Hotel. 

♦ Technical Exhibitors 

The technical exhibits will be located on the 
Mezzanine and lobby floors of the Sheraton-Pea- 
body Hotel. They may be visited each day of 
the Annual Meeting beginning on Thursday, April 
12, from 9:00 A.M. until 5:00 P.M. —and con- 
tinued from 9:00 A.M. until 5:00 P.M. on Friday, 
April 13. The exhibits will be open from 9:00 
A.M. until 1:30 P.M. on Saturday, April 14. 

The exhibitors are an important part of the 
138th Annual Meeting, and each physician is 
urged to spend a part of his time visiting and 
inspecting the products and services of the ex- 
hibitors. The exhibits will display many educa- 
tional features of medical supply and the latest 
developments in scientific undertaking. Also, many 
exhibitors will be presenting their services that are 
essential to the practice of the physician. 


TECHNICAL EXHIBITORS 
PERSONNEL 

Representatives of the companies hsted will be 
present in the exhibit area each day, to discuss the 
displays which will be on exhibit. This will give 
each registrant an opportunity to discuss products 
and services displayed with trained personnel in a 
relaxed atmosphere and to have a leisurely visit 
with the local detail man who can normally be 
seen only between patients. 

Visit Exhibitors — Through theii* rental of exhibit 
space, the commercial firms have greatly assisted 
in financing the 1973 annual meeting. Every 
physician should show his appreciation by visiting 
every exhibit. 

Hours — Exhibitor representatives will be on 
duty from 9:00 a.m. to 5:00 p.m. each day— 
Thursday through Friday, and from 9:00 A.M. 
’til 1:30 P.M. on Saturday. 

The newest developments in pharmaceuticals, 
supplies, equipment and services will be on dis- 
play, with complete information available. 

All physicians will find their time well spent in 
visiting exhibits and keeping abreast of what is 


MARCH, 1973 


249 


new and useful. YOUR ATTENDANCE IS 
URGED, for your benefit as well as for an expres- 
sion of cooperation with our exhibitors. 

VISIT THE EXHIBITS 

All scientific meetings will be recessed twice for 
thirty minutes on each day to give doctors an 
opportunity to visit with the exhibitors. 

William V. Wallace 
Exhibit Manager 


ABBOTT LABORATORIES 
North Chicago, Illinois 

ACME VISIBLE RECORDS, INC. 
Nashville, Tennessee 

AMES COMPANY 

Div. Miles Laboratories 
Elkhart, Indiana 

ARNAR-STONE LABORATORIES, INC. 
Mt. Prospect, Illinois 

AYERST LABORATORIES 
New York, New York 

BLUE CROSS-BLUE SHIELD 
Chattanooga, Tennessee 

BRISTOL LABORATORIES 
Syracuse, New York 

COCA-COLA COMPANY 
Memphis, Tennessee 


Booth 54 
Booth 36 

Booth 35 
Booth 56 
(Lobby) Booth 3 
Booth 55 
(Lobby) Booth 12 
Booth 41 


DePUY MANUFACTURING COMPANY 
Warsaw, Indiana (Lobby) Booth 13 


DICTAPHONE 
Rye, New York 

DOW PHARMACEUTICALS 
Indianapolis, Indiana 


(Lobby) Booth 2 


EQUITABLE LIFE ASSURANCE SOCIETY 
Nashville, Tennessee 

FARRINGER AND COMPANY 
Nashville, Tennessee 

FLINT LABORATORIES 
Deerfield, Illinois 


Booth 25 


Booth 23 


Booth 42 


Booth 26 


HOECHST PHARMACEUTICAL COMPANY 
Somerville, New Jersey (Lobby) Booth 1 


Booths 37 & 38 


HOFFMANN-LaROCHE 
Nutley, New Jersey 

INTRAV 

St. Louis, Missouri Booth 47 

INVESTMENT RETIREMENT TRUST 
(Denby Brandon Company) 

Memphis, Tennessee Booth 50 

LANIER BUSINESS PRODUCTS 
Atlanta, Georgia Booth 20 

ELI LILLY AND COMPANY 

Indianapolis, Indiana Booth 44 

MEMPHIS REGIONAL MEDICAL PROGRAM 
Memphis, Tennessee Booth 21 

MUTUAL BENEFIT LIFE INSURANCE 
(Dunn-Lemly-Sizer) 

Nashville, Tennessee Booth 43 

NASHVILLE SURGICAL SUPPLY 
Nashville, Tennessee Booth 51 


ORTHO PHARMACEUTICALS 
Raritan, New Jersey 

PARKE, DAVIS AND COMPANY 
Detroit, Michigan 

PFIZER LABORATORIES 
Doraville, Georgia 

PHYSICIANS BUSINESS BUREAU 
Nashville, Tennessee 


Booth 40 


Booth 48 


Booth 22 


Booth 53 


WILLIAM P. POYTHRESS & COMPANY, INC. 

Richmond, Virginia Booth 49 


A. H. ROBINS COMPANY 
Richmond, Virginia 

W. B. SAUNDERS COMPANY 
Philadelphia, Pennsylvania 

SCHERING LABORATORIES 
Kenilworth, New Jersey 


(Lobby) Booth 4 
(Lobby Booth 6 
Booth 46 


SMITH, REED, THOMPSON & ELLIS COMPANY 
Nashville, Tennessee Booth 57 


E. R. SQUIBB AND SONS 
Princeton, New Jersey 

STEWART OXYGEN SERVICE 
Memphis, Tennessee 

STUART PHARMACEUTICAL 
Wilmington, Delaware 

TENNESSEE GUILD OPTICIANS 
Nashville, Tennessee 

TENNESSEE MID-SOUTH RMP 
Nashville, Tennessee 

UPJOHN COMPANY 
Memphis, Tennessee 

UNIVERSITY OF TENNESSEE 
Continuing Medical Education 
Memphis, Tennessee 


Booth 52 


Booth 45 


Booth 19 


Booth 24 


(Lobby) Booth 7 


Booth 39 


Booth 30 


The Tennessee Medical Association greatly appreciates 
the support of the following pharmaceutical company 
in lieu of an exhibit. 

GEIGY PHARMACEUTICALS 
Ardsley, New York 


Announcements 

SPECIAL EVENTS 
AND 

FEATURES 

'k 'k 'k 

PRESIDENTS RECEPTION 
AND BANQUET 

FRIDAY, APRIL 13-7:00 P.M. 
President’s Reception— 6:00 P.M. 
Sponsored by TMA 

Wm. T. Satterfield, Sr., M.D., President, 
Presiding 

Introduction of President-Elect— 

O. Morse Kochtitzky, M.D. 

Special Awards: 

Presenting Tennessee’s Outstanding Physician of 
the Year— By Robert H. Haralson, Jr., M.D., 
Speaker of the House of Delegates 


250 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Presenting the Distinguished Service Award— 
By: C. Gordon Peerman, Jr., M.D., Chairman, 
Board of Trustees 

Presenting Health, Project Contest Winner— By: 
James W. Hays, M.D., Treasurer 

The banquet is for TMA members, their wives 
and guests. Join your friends in dining and 
dancing to the music of Tony Barrasso and his 
orchestra. 

The evening’s entertainment will be the national- 
ly rated musical group “The Stonemans.” This is a 
popular music group, known and appearing on 
such productions as the Tonight Show, Danny 
Thomas Special, Grand Ole Opry and numerous 
others. 

★ ★ ★ 

Public Health Coimcil 

The meeting of the Public Health Council will 
be held in Room 314, Sheraton-Peabody Hotel on 
Friday, April 13. The meeting will begin at 10:00 
A.M. Members of the PubHc Health Council v^dll 
be advised of other details of the meeting. 

★ ★ ★ 

Please Reserve Luncheon Tickets Early 

A number of the specialty societies meeting with 
TMA will sponsor luncheons during the Annual 
Meeting. 

PLEASE MAKE RESERVATIONS FOR 
LUNCHEONS YOU ARE PLANNING TO AT- 
TEND. (These should be made with the secretary 
of the respective specialty society.) 

TENNESSEE CHAPTER 
AMERICAN COLLEGE OF 
SURGEONS 
Thursday, April 12, 1973 
12:00 Noon 

COUNCIL LUNCHEON 
Room 314 Sheraton-Peabody 

★ ★ ★ 

COLOR TV-PRIZE 

Don’t forget to obtain your instructions and card 
to be punched by the exhibitors so that you will 
have a chance on the drawing for the portable 
color television. The drawing will be held Satur- 
day Afternoon, April 14th. Complete details can 
be obtained at the registration desk. 

★ ★ ★ 

MEDICINE & REUGION 
COMMITTEE BREAKFAST 
Saturday, April 14 
7:00 A.M. 

Venetian Room 
Sheraton-Peabody Hotel 

The speaker will be J. Frank Walker, M.D., 
Atlanta, Georgia. Dr. Walker is the speaker of the 
AMA House of Delegates. 

★ ★ ★ 


Tennessee Chapter — ^American 
College of Surgeons — Banquet 

The Tennessee Chapter of the American College 
of Surgeons will conduct their Social Hour at 6:30 
P.M., and the banquet at 7:30 P.M. on Thursday 
evening, April 12 in the Continental Ballroom of 
the Sheraton-Peabody Hotel. 

TMA MEMBERS AND THEIR GUESTS ARE 
INVITED TO ATTEND THE SOCIAL HOUR 
AND BANQUET. 


NOTICE 

(First Session) 

HOUSE OF DELEGATES 
Wednesday, April 11 
Forest Room 
Sheraton-Peabody 
4:00 P.M. 


★ ★ ★ 

NOTICE 

Seientific Presentations 
The scientific presentations of aU of the specialty 
societies meeting concurrently with the Tennessee 
Medical Association, are open to all physicians 
registered at the Annual Meeting. Attend the 
meeting of your choice. 

Technical Exhibits 

The technical exhibits are located in the exhibit 
area in the Sheraton-Peabody. They are open daily 
at 9:00 A.M. 

TMA Board of Trustees Meeting 
The TMA Board of Trustees will meet in Room 
202 of the Sheraton-Peabody Hotel at 9:00 A.M. 
on Sunday, April 15. 

★ ★ ★ 

Tennessee — Trauma Committee 
and Emergency Medical 
Service Committee 
Friday, April 13, 1973 
Luncheon — 12:00 Noon 
Room 213 

Sheraton-Peabody Hotel 

★ ★ ★ 

IMPACT BREAKFAST 
FRIDAY, APRIL 13, 1973 

8:00 A.M. 

Venetian Room — Sheraton-Peabody Hotel 

★ ★ ★ 


MARCH, 1973 


251 


Woman’s Auxiliary to the 
Tennessee Medical Association 


SCIENTIFIC PROGRAM 

B. F. Benton, M.D., President, Presiding 


45th Annual Convention 
April 12-14, 1973 
Albert Pick Motor Inn 
Memphis 

The Woman’s Auxiliary to the TMA will con- 
duct all sessions of its annual meeting at the 
Albert Pick Motor Inn with the exception of Fri- 
day’s luncheon and general session. The regis- 
tration desk of the Auxiliary will be located in the 
Albert Piek Motor Inn, and all committee meetings, 
board meetings, and Saturday’s general sessions 
will be conducted in the designated rooms at the 
Albert Pick Motor Inn. 

★ ★ ★ 

Arts and Crafts Exhibit and 
AMA-ERF Gift Shop 

The Arts and Crafts Exhibit of the Woman’s 
Auxiliary will be located on the eleventh floor of 
the Albert Piek, Motor Inn. Arts and crafts will 
be accepted Thursday, April 12, from 2:00-5:00 
P.M., and on Friday, April 13, from 9:00 A.M. un- 
til 12:00 Noon. Doctors and their families are 
urged to partieipate in the exhibit. The AMA-ERF 
Gift Shop will also be located on the eleventh 
floor. Items for sale will be donated by local 
auxiliaries to augment Tennessee’s contribution to 
the AMA-ERF Fund. 


PROGRAM 

Thursday, April 12, 1973 

SPECIALTY SOCIETIES 

★ ★ ★ 

TENNESSEE CHAPTER 
AMERICAN COLLEGE OF 
SURGEONS 

12:00 NOON 

COUNCIL 

Luncheon Meeting 

Room 314 Sheraton-Peabody Hotel 

GENERAL MEETING 

Forest Room Sheraton-Peabody Hotel 

(All physicians attending the TMA meeting are 
invited to attend the scientific sessions of the 
Tennessee Chapter, American College of Sur- 
geons.) 


1:30 P.M. 

“Bacteroides Infections” 

By: Eugene R. Nobles, M.D., F.A.C.S., Memphis 

1:45 P.M. 

Discussion 

1:50 P.M. 

“New Experiences in Treatment of Enterocuta- 
neous Fistulas” 

By: John E, Kesterson, M.D., F.A.C.S., Knoxville 

2:05 P.M. 

Discussion 

2:10 P.M. 

“Use of X-ray (Faxtron) in Operative Localization 
of Cancer of the Breast” 

By: Robert Lerman, M.D., Memphis 

2:25 P.M. 

Discussion 

2:30 P.M. 

“Ideal Bypass for Morbid Obesity” 

By: H. William Scott, M.D., F.A.C.S., Nashville 

2:45 P.M. 

Discussion 

2:50 P.M.-3:05 P.M. 

Intermission— Visit Exhibits 

3:05 P.M. 

“Management of Retained Common Duct Stones” 
By: Robert P. McBurney, M.D., F.A.C.S., Mem- 
phis 

3:20 P.M. 

Discussion 


3:25 P.M. 

“Carcinoma of the Skin in Black Patients” 

By: Irvin D. Fleming, M.D., F.A.C.S., Memphis 

3:40 P.M. 

Discussion 

3:45 P.M. 

GUEST SPEAKER 

“Results of Surgery for Coronary Artery Insuf- 
ficiency in Myocardial Infarction” 

By: Denton A. Cooley, M.D., F.A.C.S., Houston, 
Texas 

7:00 P.M. 

SOCIAL HOUR AND BANQUET 

Continental Ballroom 

TMA members and their guests are invited to at- 
tend the Social Hour and Banquet. Make reserva- 
tions early. Tickets available at registration desk. 

★ ★ ★ 


252 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


TENNESSEE ACADEMY OF 
OPHTHALMOLOGY 
THURSDAY, APRIL 12, 1973 

12:00 NOON 

Grand Salon — ^East Downtowner Motor Inn 

LUNCHEON AND PANEL 
DISCUSSION 

Panelists; Fred C. Blodi, M.D. 

Iowa City, Iowa 
J. Brooks Crawford, M.D. 

San Francisco, California 
Dennis O’Day, M.D. 

Nashville 

SCIENTIFIC PROGRAM 

Grand Salon — ^West Downtowner Motor Inn 


TENNESSEE STATE 
ORTHOPAEDIC SOCIETY 

THURSDAY, APRIL 12, 1973 
Room 200 Sheraton-Peabody Hotel 

SaENTIFIC PROGRAM 

9:00 A.M. 

(Moderator: Moore Moore, Jr., M.D., Memphis) 
WELCOME-B. G. MITCHELL, M.D., President 

9:15 A.M. 

‘Locked Cervical Facets in Dislocated Cervical 
Spines” 

By: Warren Castle, M.D. and Bryan Noah, 
M.D., Nashville 

9:35 A.M. 

Discussion 


1:10 P.M. 

Meeting Called to Order 
By: David H. Turner, M.D., President 

1:15 P.M. 

“A Review of Malignant Melanoma of the Choroid” 
By: Albert Laws, M.D., David Meyer, M.D., 
and Jerry Luther, M.D., Memphis 


9:45 A.M. 

“Spine Fractmres With Neurological Impairment — 
Anterior Decompressions and Stabilization” 

By: Don Gaines, M.D. and Arthur Brooks, 
M.D., Donelson 

10:05 A.M. 

Discussion 


1:35 P.M. 

“Pseudoghoma — A Study in 2 Brothers” 

By: Larry R. Moorman, M.D., Chattanooga 

1:50 P.M. 

GUEST SPEAKER 

“Malignant Orbital Tumors” 

By: Fred C. Blodi, Iowa City, Iowa 

2:50 P.M. 

Intermission— Visit Exhibits 

SCIENTIFIC PROGRAM 

(Continued) 

3:05 P.M. 

“Tonometry — A Comparison of Methods” 

By: Lee Mullis, M.D., Chattanooga 

3:15 P.M. 

GUEST SPEAKER 

“Hidden Carcinoma of the Ocular Adnexia” 

By: J. Brooks Crawford, M.D., San Francisco, 
California 

4:15 P.M. 

“Photoinactivation of Ocular Herpes” 

By: Denis O’Day, M.D., Nashville 

4:30 P.M. 

“Trabeculotomy and Trabeculectomy” 

By: Richard Baker, M.D., Memphis 

★ ★ ★ 


10:15 A.M. 

“Results From the Use of Walldius Knee Joint 
Prosthesis” 

By: David Jones, M.D., Nashville 

10:35 A.M. 

Discussion 

10:45 A.M. 

“My Early Experience With the Modified Geo- 
medic Knee” 

By: J. MacDonald Burkhart, M.D., Knoxville 

11:05 A.M. 

Discussion 

11:15 A.M. 


GUEST SPEAKER 

“Polycentric and Geometric 
Total Knee Arthroplasty” 

By: R. S. Bryan, M.D., 
Rochester, Minnesota 


R. S. Bryan, M.D. 

12:15 P.M. 

LUNCHEON 

Louis XVI Room Sheraton-Peabody Hotel 

SCIENTIFIC PROGRAM 

(Continued) 



MARCH, 1973 


253 



1:15 P.M. 

Room 200 Sheraton-Peabody Hotel 

(Moderator: W. L. Moffatt, M.D., Memphis) 
“Promotion of Fracture Healing Strength By 
Electrical Stimulation” 

By: Joe Ortiz, M.D., Nashville 

1:35 P.M. 

Discussion 

1:45 P.M. 

“Causal Relationship Between Avascular Necrosis 
of the Femoral Head and Degenerative Arth- 
ritis of the Hip” 

By: R. A. Calandruccio, M.D., Memphis 

2:05 P.M. 

Discussion 

2:15 P.M. 

“Management of the Severely Deformed Spine” 
By: Don Gaines, M.D., Donelson 

2:35 P.M. 

Discussion 

2:45 P.M. 

“Follow-up of Milwaukee Brace Treatment for 
Ideopathic Scoleosis” 

By: A. S. Edmondson, M.D., Memphis 

3:05 P.M. 

Discussion 

3:15 P.M. 

“Conservative Treatment of Roth Bone Fractures 
of the Leg” 

By: W. C. Hutchins, M.D., Memphis 

3:35 P.M. 

Discussion 

6:30 P.M. 

SOCIAL HOUR AND BANQUET 

Memphis Country Club 

★ ★ ★ 

TENNESSEE THORACIC SOCIETY 

THURSDAY, APRIL 12, 1973 

(Harry L. Davis, M.D., Secretary— Presiding) 
Flagship Room Downtowner Motor Inn 

1:15 P.M. 

“Coronary Artery By-Pass Surgery” 
Medical Aspects— Donald R. Eubanks, M.D. 
Surgical Aspects— James W. Pate, M.D. 
Discussion 


2:15 P.M. 

“The Dyspneic Patient” 

(John P. Griffin, M.D.— Moderator) 
DiflFerential Diagnosis— William I. Mariencheck, 
M.D. 

Laboratory Evaluation— William A. Potter, M.D. 
Adult Respiratory Distress Syndrome (“Shock 
Lung”)— Philip E. Duncan, M.D. 

Discussion 

3:15 P.M. 

Intermission— Visit Exhibits 

3:30 P.M. 

“El Toro Session” 

(Francis H. Cole, M.D.— Moderator) 
Presentation of Interesting and Unusual Pulmonary 

Cases 

4:30 P.M. 

BUSINESS MEETING 

★ ★ ★ 

TENNESSEE PEDIATRIC SOCIETY 
AND 

TENNESSEE ACADEMY OF 
FAMILY PHYSICIANS 

(Joint Meeting) 

THURSDAY, APRIL 12, 1973 

SCIENTIFIC PROGRAM 

Room 216 Sheraton-Peabody Hotel 

1:00 P.M. 

“Headache in Children” 

2:00 P.M. 

“Epilepsy” 

3:00 P.M. 

Questions and Discussion 
Gerald M. Fenichel, M.D., Professor and Chair- 
man Neurology, Vanderbilt Medical School 
(Pediatricians are invited to meet with the Ten- 
nessee Society of Pathology on Saturday, April 14, 
1973, from 1:00 to 5:30 P.M., on IMMUNOLOGY. 

★ ★ ★ 

TENNESSEE DISTRICT BRANCH— 
AMERICAN PSYCHIATRIC 
ASSOCIATION 

THURSDAY, APRIL 12, 1973 
Galleries (Room 527) Downtowner Motor Inn 

SCIENTIFIC PROGRAM 

9:00 A.M. 

“Psychological Problems of the Disadvantaged” 

By: Jeanne Spurlock, M.D., Professor of Psy- 
chiatry, Meharry Medical College 


254 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


9:45 A.M. 

“The Psychophysiological Aspect of Cancer” 

By: James Mathis, M.D., Professor of Psychiatry, 
Medical College of Virginia 

10:30 A.M.-11:00 A.M. 

Intermission— Visit Exhibits 

11:00 A.M. 

PANEL DISCUSSION 

“The Psychiatric Revolution — A Twenty-Year Ret- 
rospective” 

(Participants to be Announced) 

12:15 P.M. 

LUNCHEON 

Plantation Room Downtowner Motor Inn 

1:30 P.M. 

Business Meeting 

Galleries (Room 527) Downtowner Motor Inn 

3:00-3:30 P.M. 

Intermission— Visit Exhibits 

3:30-5:00 P.M. 

BUSINESS MEETING 

6:30 P.M. 

Cocktail Hour and Banquet 

Grand Salon — ^East Downtowner Motor Inn 

★ ★ ★ 

TENNESSEE SOCIETY OF 
PLASTIC AND 

RECONSTRUCTIVE SURGEONS 

THURSDAY, APRIL 12, 1973 

12:15 P.M. 

LUNCHEON 

Levee Room Downtowner Motor Inn 

1:15 P.M. 

SCIENTIFIC PROGRAM 

“Maxillofacial Prosthedontia” 

By: G. A. McCarty, Jr., D.D.S., Houston, Texas 
“Fractmes of the Zygomatico Maxillary Complex — 
10 Year Review” 

By: Manoucher Faiz, M.D. and Cauley Hayes, 
M.D., Chattanooga 
“Blepharoplasty” 

By: McCarthy DeMere, M.D., Memphis 
“Cervicofacial Flap” 

By: Allen Hughes, M.D., Memphis 
“Carpal Tunnel Syndrome From a Rare Cause” 
By: Cauley Hayes, M.D., Chattanooga 
“Keratosis Palmaris Et Plantaris” 

By: W. H. Kisner, M.D., Memphis 
“Surgical Management of Large Nevi” 

By: William Milton Adams, M.D., Memphis 


“Complications of Mammary Replacement Follow- 
ing Simple Mastectomy” 

By: James H. Fleming, M.D., Nashville 
“Surgical Treatment of Skin Cancer” 

By: John B. Lynch, M.D., Nashville 

★ ★ ★ 

WOMAN’S AUXILIARY TO THE 
TENNESSEE MEDICAL 
ASSOCIATION 

THURSDAY, APRIL 12, 1973 
Albert Pick Motor Inn 

PROGRAM 

10:00 A.M.-12-.00 Noon 
Meeting of Finance and Revisions Committees, 
President’s Suite, Rooms 1120-1121 

1:00-2:00 P.M. 

Pre-convention Board Meeting 
Shelby Room 

2:00-3:00 P.M. 

Meeting of Awards Committee 
President’s Suite, Rooms 1120-1121 

2:00-5:00 P.M. 

Registration, Lobby 
Hospitality Room, 11th Floor 
Entries Accepted for Arts and Crafts 
AMA-ERF Gift Shop, Scrapbooks, 
Doctors’ Day Scrapbooks 

PROGRAM 
Friday, April 13, 1973 

IMPACT BREAKFAST 

Venetian Room Sheraton-Peabody Hotel 

8:00 A.M. 

Program 


■IMPACT Guest Speaker 



Congressman Robin Beard 


MARCH, 1973 


255 


Tennessee’s newest Congressman, Robin L. Beard 
will be the guest speaker at this year’s IMPACT (In- 
dependent Medieine’s Politieal Aetion Committee- 
Tennessee) Breakfast. One of the highlights of the 
TMA meeting annually, the Breakfast will be held in 
the Sheraton-Peabody Hotel’s Venetian Room at 8:00 
a.m. on Friday, April 13, 1973. Tickets will be on 
sale at the Main Registration Desk. 

A Republican, Congressman Beard was born in 
Knoxville but grew up in the Nashville area. He is 
a graduate of Vanderbilt University and served with 
distinction as an Officer in the Marine Corps. 

A campaign coordinator for Winfield Dunn in his 
successful bid for Governor in 1970, Mr. Beard was 
named Commissioner of Personnel by Governor Dunn, 
a post he held for two years. 

Representative Beard defeated 4-term Democratic 
Congressman William Anderson last November by a 
17,000 vote margin, making him the youngest member 
of the Tennessee Congressional Delegation and the 
youngest Congressman ever elected from his district. He 
serves on the powerful House Armed Services Com- 
mittee. 

IMPACT is fortunate to have obtained Congressman 
Beard as the 1973 Breakfast Speaker. Be smre to get 
your tickets early as space will be limited. 

TMA General Program 

Continental Ballroom Sheraton-Peabody Hotel 

Presiding: Harry A. Stone, M.D., Chattanooga, 
Chairman, Program Committee, 
Tennessee Medical Association. 


9:45 A.M. 

“Emergency Physicians” 

By: Ralston R. Hannas, Jr., M.D. 

Director of Services 
Evanston Hospital 
Evanston, Illinois 

“A Layman’s Viewpoint of Health Care 
Delivery” 

By: Harry Schwartz, Ph.D. 

Editorial Board 

The New York Times 

New York City, New York 

“A Legislator’s Viewpoint of Health Care 
Delivery” 

By: The Honorable Wilbur D. Mills 

Chairman, Ways and Means Committee 
U. S. House of Representatives 
Washington, D. C. 

Visit Exhibits 


•TMA Guest Speaker 



Ralston R. Hannas, Jr., M.D. 
Director of Emergency Services 
Evanston Hospital, Illinois 


SUBJECT: “Emergency Physicians” 

An authority on emergency medicine, Dr. 
Hannas is the Director of Emergency Services at 
Evanston Hospital in Evanston, Illinois. He serves 
the American College of Emergency Physicians as 
Vice Chairman of the Board of Directors, Chair- 
man of the Commission on Education, and Chair- 
man of the Scientific Assembly. Further, he is on 
the Committee on Emergency Health Services, 
Council on Professional Services, and Special Com- 
mittee on the Provision of Health Services (Perloff 
Committee) of the American Hospital Association. 

In April 1968, Dr. Hannas formed an Emer- 
gency Physicians Group in Kansas City which 
eventually provided full-time emergency physician 
coverage at 3 hospitals in the area. 

Dr. Hannas began a distinguished career in 
medicine in Sentinel, Oklahoma where he was a 
partner in private practice in a small hospital and 
clinic for more than 12 years. During this period, 
he was an active member of the Oklahoma State 
Medical Association and Assistant Clinical Professor 
of Medicine at the University of Oklahoma Medical 
School. 

A native of New Jersey, Hannas received an 
undergraduate degree at Purdue University and 
the M.D. degree at Harvard Medical School. 


256 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



■TMA Guest Speaker 


■TMA Guest Speaker 



Harry Schwartz, Ph.D. 
Editorial Board 
The New York Times 


SUBJECT: “A Layman’s Viewpoint of Health 
Care Delivery” 

The author of the recently published book, The 
Case for American Medicine, Dr. Schwartz has 
become a leading lay spokesman on health care 
problems in the United States. He has written 
numerous articles on scientific and medical matters 
for The New York Times and other noted publica- 
tions. 

“If the revolutionary proposals for transforming 
medicine are adopted, medical care in this country 
will cost more while providing less satisfaction 
and poorer treatment for millions,” he stated in the 
August 14, 1971 edition of The Saturday Review. 

Dr. Schwartz is also a well-known economist 
and specialist on Soviet Affairs. He has served 
as an economist with the War Production Board, 
the Department of Agriculture and Department of 
State, and was a specialist on Soviet economic 
intelligence with the Office of Strategic Service 
during World War II. An alumnus of Columbia 
University where he received the B.A., M.A., and 
Ph.D. degrees. Dr. Schwartz has held professor- 
ships at Syracuse University, Columbia University, 
New York University, American University and 
Brooklyn College. Currently, he is University Pro- 
fessor at State University College in New York. 



The Honorable Wilbur D. Mills 
U. S. House of Representatives 
( Democrat- Arkansas ) 

SUBJECT: “A Legislator’s Viewpoint of Health 
Care Delivery” 

As chairman of the pivotal House Ways and 
Means Committee, Congressman Mills is a key 
figure in the development of national health in- 
surance legislation. 

“The impetus for real and lasting change in 
our health system to meet its problems must come 
largely from those working within the system. The 
problems of rising costs, of disorganized and in- 
effective methods of providing health care, of in- 
creasing dependence on foreign medical graduates 
so desperately needed in their own countries, and 
other problems . . . cannot be solved by govern- 
ment alone. Legislation can effectively support 
forces for change; it cannot create them,” Mills 
said, before the American Society of Internal Medi- 
cine. 

Mr. Mills has been a member of Congress for 
33 years. He was named to the Ways and Means 
Committee in October, 1942; and in 1958 was 
elected chairman, the youngest in the history of 
the Committee. He serves as chairman of the 
House Committee on Committees and vice chair- 
man of the Joint Committee on Internal Revenue 
Taxation. A native of Kensett, Arkansas, Chairman 
Mills is a graduate of Hendrix College and Har- 
vard Law School. 


MARCH, 1973 


257 




The President’s Reception and 
BANQUET 

FRUJAY, APRIL 13, 1973 
Sheraton-Peabody Hotel 
Continental Ballroom 
Memphis, Tennessee 

PROGRAM 

William T. Satterfield, Sr., M.D., President 
Tennessee Medical Association 
RECEPTION-6:00 P.M. 
BANQUET-7;00 P.M. 

DANCING 

To the Music of Tony Barrasso 
and His Orchestra 

★ ★ ★ 

Events Include 

★ Introduction of Distinguished Guests Attend- 
ing the Annual Meeting 

★ Presenting the Outstanding Physician of the 
Year in Tennessee 

★ Special Awards to the Winning Representatives 
of The Health Project Contest 

★ Presenting the Distinguished Service Award 

★ Installation of the Incoming President 

★ Fun— Entertainment— Dancing 

★ ★ ★ 

Obtain Tickets at Registration 
Desk in the Sheraton-Peabody 

Friday Evening 
April 13, 1973 

SPECIAL ENTERTAINMENT— 
TMA BANQUET 

Friday Evening, April 13 in the 
Sheraton-Peabody Hotel 



“The Stonemans” 


The singing . . . swinging . . . stomping . . . 
sensational . . . Stonemans, “vocal group of the 
year” Colorful and accomplished . . . and their 
auto-haips, mandolins and toe-tapping tamborines 
bring any gathering to its feet with applause for 
MORE! The Stonesmans have been on special 
personal appearances on such TV shows as the 
Danny Thomas Special— Steve Allen Show— Tonight 
Show— NBC Documentary “Music From the Land” 
—Hollywood Palace— Glen Campbell Show— Grand 
Ole Opry— and many others. You can’t afford to 
miss this special entertainment, one of the best 
musical groups ever to appear at our banquet. 

★ ★ ★ 

SPECIALTY SOCIETIES 

TENNESSEE STATE 
ORTHOPAEDIC SOCIETY 

FRIDAY, APRIL 13, 1973 

Room 200 Sheraton-Peabody Hotel 

SCIENTIFIC PROGRAM 

1:00 P.M. 

“Avascular Necrosis of the Femoral Head in Ma- 
ture and Immature Dogs” 

By: Donald C. Henard, M.D., Memphis 

1:20 P.M. 

Discussion 

1:30 P.M. 

GUEST SPEAKER 

“Difficulties and Complications with Total Hip 
Arthroplasty” 

By: R. S. Bryan, M.D., Rochester, Minnesota 
2:00 P.M. 

“Current Orthopaedic Situation in Vietnamese 
Civilian Hospitals” 

By: Paul Spray, M.D., Oak Ridge 

2:20 P.M. 

Discussion 

2:30 P.M. 

“High Pressure Injection Injuries of the Hand” 
By: Lee W. Milford, M.D., Memphis 

2:50 P.M. 

Discussion 

3:00 P.M. 

“Congenital Vertical Talus in Adults” 

By: John Connolly, M.D., Nashville 

3:20 P.M. 

Discussion 

3:30 P.M. 

“Unilateral Posterio-Lateral Spinal Fusion” 

By: D. J. Scott, Jr., M.D., Memphis 


258 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


3:50 P.M. 

Discussion 

4:00 P.M. 

Annual Business Meeting 

★ ★ ★ 

TENNESSEE TRAUMA COMMITTEE 

AND 

EMERGENCY MEDICAL SERVICES 
COMMITTEE 
FRIDAY, APRIL 13, 1973 

12:00 NOON 

LUNCHEON AND SCIENTIFIC 
MEETING 

Room 213 — Sheraton-Peabody Hotel 

★ ★ ★ 

TENNESSEE ASSOCIATION 
OF PUBLIC HEALTH PHYSICIANS 

FRIDAY, APRIL 13, 1973 
Levee Room Downtowner Motor Inn 

1:15 P.M. 

ORGANIZATIONAL AND 
BUSINESS MEETING 

★ ★ ★ 

TENNESSEE ACADEMY OF 
OTOLARYNOLOGY 

FRIDAY, APRIL 13, 1973 

1:15 P.M. 

Room 370 Sheraton-Peabody Hotel 

ORGANIZATIONAL MEETING 
★ ★ ★ 

TENNESSEE OBSTETRICAL AND 
GYNECOLOGICAL SOCIETY 

FRIDAY, APRIL 13, 1973 
Room 214 Sheraton-Peabody Hotel 

12:00 NOON 

COCKTAILS 

(Courtesy of Reid-Provident Laboratories) 
12:30 P.M. 

LUNCHEON 

(Tennessee State Obstetrical and 
Gynecological Society Only) 

1:30 P.M. 

Intermission— Visit Exhibits 

SCIENTIFIC PROGRAM 

Stewart A. Fish, M.D., President, Presiding 
2:00 P.M. 

BUSINESS MEETING 


2:15 P.M. 

SCIENTIFIC PRESENTATION 

“Management of the Pregnant Diabetic” 

By: John Morrison, M.D., Assistant Professor 
of the Department of Obstetrics and Gyne- 
cology at the University of Tennessee College 
of Medicine 

2:45 P.M. 

“The Post Mature Infant Syndrome” 

By: George Ellis, M.D., Resident of Obstetrics 
and Gynecology at the City of Memphis Hos- 
pitals 

3:15 P.M. 

“Hemoclip Tubal Sterilization” 

By: Sidney W. Arnold, M.D., Assistant Professor 
of the Department of Obstetrics and Gyne- 
cology at the University of Tennessee College 
of Medicine 

3:45 P.M. 

COFFEE BREAK 

and Visit Exhibits 
4:00 P.M. 

PANEL DISCUSSION 

“Abruptio Placenta* 

Panelists: 

John Morrison, M.D., Assistant Professor of 
the Department of Obstetrics and Gynecology at 
the University of Tennessee College of Medicine; 
W. L. Wiser, M.D., Associate Professor of tlie 
Department of Obstetrics and Gynecology at the 
University of Tennessee 

Stewart A. Fish, M.D., Professor and Ghair- 
man of the Department of Obstetrics and Gyne- 
cology at the University of Tennessee College of 
Medicine 

4:30 P.M. 

ADJOURNMENT 

★ ★ ★ 

TENNESSEE ACADEMY OF 
OPHTHALMOLOGY 

FRIDAY, APRIL 13, 1973 

11:00 A.M. 

BUSINESS MEETING 

Grand Salon — West Downtowner Motor Inn 

12:30 P.M. 

LUNCHEON AND PANEL 
DISCUSSION 

Grand Salon — ^East Downtowner Motor Inn 

Panelists: Fred C. Blodi, M.D. 

Iowa Gity, Iowa 
J. Brooks Crawford, M.D. 

San Francisco, California 
Denis O’Day, M.D. 

Nashville 

SCIENTIFIC PROGRAM 

Grand Salon — West Downtowner Motor Inn 


MARCH, 1973 


259 


1:40 P.M. 

Meeting Called to Order 
By: Allen G. Lawrence, Jr., M.D., 

Vice President 

1:45 P.M. 

“Orbital Tumor and Amblyopia — ^A Case Report” 
By: Harry M. Lawrence, M.D., Chattanooga 

1:55 P.M. 

“Oculopharyngeal Muscular Dystrophy” 

By: Fred Slaughter, M.D., Bristol 

2:10 P.M. 

GUEST SPEAKER 

“Tumor, Trauma Relationships” 

By: J. Brooks Crawford, M.D., San Francisco, 
California 

3:10 P.M. 

Intermission— Visit Exhibits 

3:20 P.M. 

“Band Keratopathy” 

By: George Walker, M.D., and Thomas O. 
Wood, M.D., Memphis 

3:30 P.M. 

GUEST SPEAl^R 

“Unusual Comeal Degeneration” 

By: Fred C. Blodi, M.D., Iowa City, Iowa 

4:30 P.M. 

“Gas Gangrene Endophthalmitis” 

By: Larry Sauls, M.D., Denis O’Day, M.D., and 
Wilkes, M.D., Nashville 

★ ★ ★ 

TENNESSEE DIABETES 
ASSOCIATION 

FRIDAY, APRIL 13, 1973 

12:15 P.M. 

LUNCHEON 

Louis XVI Room Sheraton-Peabody Hotel 

SaENTIFIC PROGRAM 

Louis XVI Room Sheraton-Peabody Hotel 

1:00 P.M. 

“The Glucose Electrode and the Artificial Beta CeU 
— ^A Progress Report” 

By: J. Stuart Soeldner, M.D., Associate Pro- 
fessor of Medicine, Harvard University Medi- 
cal School; Senior Associate in Medicine, Peter 
Bent Brigham Hospital; Associate Director, 
Elliot P. Joslin Research Laboratory, Boston, 
Massachusetts 

2:00 P.M. 

“Relationship Capillary Basement Membrane 
Thickening to Aging and to Diabetic Microanio- 
pathy” 

By: Joseph R. Williamson, M.D., Associate Pro- 
fessor of Pathology, Washington University 
Medical School, St. Louis, Missouri 


2:40 P.M. 

“Autonomic Neuropathy in Diabetes” 

By: Max Ellenberg, M.D., Clinical Professor of 
Medicine, Mount Sinai School of Medicine; 
Attending Physician for Diabetes, the Mount 
Sinai Hospital, New York 

3:20 P.M. 

“Relationship of Carbohydrate Intolerance to 
Fluctuating Hearing Loss” 

By: Abbas E. Kitabchi, M.D., Ph.D., Associate 
Chief of Staff for Research, Veterans Admin- 
istration Hospital, Memphis; Professor of 
Biochemistry and Associate Professor of 
Medicine, University of Tennessee Medical 
Units, Memphis, Tennessee, and JOHN J. 
SHEA, M.D. 

4:00 P.M. 

Business Meeting With Lay Group 

★ ★ ★ 

TENNESSEE NEUROSURGICAL 
SOCIETY 

FRIDAY, APRIL 13, 1973 
Room 202 Sheraton-Peabody Hotel 

SaENTIFIC PROGRAM 

1:15 P.M. 

(Moderator: Bland W. Gannon, M.D., President, 
Memphis) 

“SYMPOSIUM ON NEW APPROACHES TO 
THE TREATMENT AND RELIEF OF PAIN” 

★ ★ ★ 

WOMAN’S AUXILIARY TO THE 
TENNESSEE MEDICAL 
ASSOCIATION 

FRIDAY, APRIL 13, 1973 
Albert Pick Motel Inn 

PROGRAM 

9:00 A.M.-4:30 P.M. 

Registration, Lobby 
Hospitality Room, 11th Floor 
Arts and Crafts 
AMA-ERF Gift Shop 

8:00 A.M. 

IMPACT BREAKFAST 

9:30 A.M.-12:00 Noon 

Members of the Woman’s Auxiliary are invited 
to attend the TMA General Sessions in the Con- 
tinental Ballroom of the Sheraton-Peabody Hotel. 


260 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


12:30 P.M. 

LUNCHEON 

Chickasaw Country Club 
Transportation will be provided at the 
Sheraton-Peabody Hotel. 

GUEST SPEAKER 

MRS. WILLARD C. SCRIVNER, President-Elect 
Woman’s Auxiliary to the AMA 

2:00-4:00 P.M. 

General Session 
Chickasaw Country Club 

PROGRAM 

Saturday, April 14, 1973 

MEDICINE AND RELIGION BREAKFAST 

Venetian Room Sheraton-Peabody Hotel 

7:00 A.M. 

Presiding: Ira L. Arnold, M.D., Chairman, Com- 
mittee on Medicine and Religion 

SPEAKER 



J. Frank Walker, M.D. 
Speaker, AMA House of Delegates 
Atlanta, Georgia 


This noted leader of organized medicine is an 
equally noted chmrchman. For many years he has 
been a dedicated member and Elder of the First 
Presbyterian Church in Atlanta. 

An Atlanta radiologist since 1953, Dr. Walker 
was elected Speaker of the AMA House of Dele- 
gates last June. He has served the AMA as a 
delegate from his state, and as a member of the 
AMA Council on Legislation and Committee on 
Health Manpower. 

He is an active member and past president of 
several medical organizations including the Medical 
Association of Atlanta, Fifth District Medical 


Society of Georgia, Atlanta Radiological Society, 
Georgia Radiological Society, and American Col- 
lege of Radiology. With the Medical Association 
of Georgia, he has served as Speaker of the House, 
Councilor, Executive Committee member, and 
chairman of numerous committees. 

A graduate of Oxford College of Emory Uni- 
versity and the Emory University College of 
Medicine, Dr. Walker is currendy an Associate 
Professor of Radiology at his ahna mater and a 
member of the Emory Board of Visitors. He is a 
past president of the Emory National Alumni As- 
sociation and a recipient of the medical alumni 
Award of Honor. 

Wives Invited 

★ ★ ★ 


9:00 A.M. 

HOUSE OF DELEGATES 
Second Session 

Forest Room Sheraton-Peabody Hotel 

SPECIALTY SOCIETIES 

★ ★ ★ 

TENNESSEE STATE SOCIETY OF 
ANESTHESIOLOGISTS 

SATURDAY, APRIL 14, 1973 
Room 213 Sheraton-Peabody Hotel 

SCIENTIFIC PROGRAM 

9:00 A.M. 

“Practical Acid-Base Balance in the Operating 
Room and After” 

By: Joachim Gravenstein, M.D., Professor and 
Chairman, Department of Anesthesia, Case 
Western Reserve University, Cleveland, Ohio 

10:00 A.M. 

INTERMISSION— EXHIBITS 

10:30 A.M. 

“Regional Anesthesia Made Simple” 

By: Alon P. Winnie, M.D., Professor and Chair- 
man, Department of Anesthesia, Abraham 
Lincoln School of Medicine, University of 
Illinois, Chicago, Illinois 

12:15 P.M. 

LUNCHEON 

Room 214 Sheraton-Peabody Hotel 

SCIENTIFIC PROGRAM 

(Continued) 

Room 213 Sheraton-Peabody Hotel 


MARCH, 1973 


261 



★ ★ ★ 


1:15 P.M. 

“How Can We Solve the Manpower Shortage?” 
By: JoACfflM Gravenstein, M.D. 

2:15 P.M. 

Contributed Scientific Papers 
4:00 P.M. 

BUSINESS MEETING 

7:00 P.M. 

“MOONLIGHT ON THE 
MISSISSIPPI” 

Memphis Queen 
Cruise and Dinner 

★ ★ ★ 

TENNESSEE SOCIETY OF 
PATHOLOGISTS 

SATURDAY, APRIL 14, 1973 

11:00 A.M. 

BUSINESS MEETING 

Room 202 Sheraton-Peabody Hotel 

12:00 NOON 

LUNCHEON 

Room 215 Sheraton-Peabody Hotel 

SCIENTIFIC PROGRAM 

Room 202 Sheraton-Peabody Hotel 

Immunology in Modem Clinical Practice 

1:00-1:45 P.M. 

“Modem Treatment of Leukemia, Results and 
Problems” 

By: Alexander A. Green, M.D., St. Jude Ghil- 
dren’s Research Hospital, Memphis 

2:00-3:45 P.M. 

“Clinical Approach to Immune Mediated Disease 
— Part I and Part H” 

By: Phil Lieberman, M.D., and Lloyd Craw- 
ford, M.D., Memphis 

4:00-5:00 P.M. 

“Techniques in a Modem Immunology Laboratory” 
By: Bruce S. Rabin, M.D., Assistant Professor of 
Pathology, School of Medicine, University of 
Pittsburgh, Pittsburgh, Pennsylvania 

5:00-5:30 P.M. 

PANEL DISCUSSION 

Panelists: Alexander A. Green, M.D. 

Phil Lieberman, M.D. 

Lloyd Crawford, M.D. 

Bruce S. Rabin, M.D. 


TENNESSEE RADIOLOGICAL 
SOCIETY 

SATURDAY, APRIL 14, 1973 
Room 216 Sheraton-Peabody Hotel 

12:15 P.M. 

LUNCHEON 

1:15 P.M. 

SCIENTIFIC PROGRAM 

“Radiology of the Spinal Cord Injury Patient” 
By: Ben Greenberg, M.D., Veterans Hospital, 
Memphis 

“The Role of Surgery and Radiology in the 
Management of Thoracolumbar Injuries” 

By: Joseph Lougheed, M.D., Memphis 

Intermission — ^Visit Exhibits 

Business Meeting 

★ ★ ★ 

WOMAN’S AUXILIARY TO THE 
TENNESSEE MEDICAL 
ASSOCIATION 

SATURDAY, APRIL 14, 1973 
Albert Pick Motel 

PROGRAM 

9:00 A.M.-12:00 Noon 
Registration, Lobby 
Hospitality Room, 11th Floor 
Arts and Crafts 
AMA-ERF Gift Shop 

7:30-9:30 A.M. 

Interfaith Prayer Breakfast and 
Combined Boards 
1972-73, 1973-74 Meeting 

Presiding: Mrs. Jere Lowe 

9:45 A.M.-12:00 Noon 
General Convention Session 
Lower Level 

12:15-2:00 P.M. 

LUNCHEON 

Lower Level 
Honoring Past Presidents 

2:00-3:00 P.M. 

Pick Up Arts and Crafts, Scrapbooks, Etc. 


262 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Slieratoii in Memphis 



Welcome ... 138th Annual Meeting 

TENNESSEE MEDICAL ASSOCIATION 

April 11-12-13-14, 1973 


For reservations 800-325-3535 makes it happen. 


We wish you a most successful and pleasurable meeting. 


The COTTON MART 
Try Restaurant 

The MINUTE CHEF 

Serving Breakfast 
Open 24 hours a day Lunch & Dinner 

Sheraton-Peabody Hotel 

^ 149 UNION AVENUE 

SHERATON HOTELS AND MOTOR INNS, A WORLDWIDE SERVICE OF ITT 


The 

FALSTAFF LOUNGE 

Open 11:00 A.M. to 1:00 A.M. 
Main Lobby Area 



MARCH, 1973 


263 



Health Goals 

We adopt the word Health Organization 
definition of health which describes it as “a 
state of complete physical, mental, and social 
well-being, and not merely the absence of dis- 
ease or infirmity.” It expresses our scope of 
interest and direction of effort. This definition, 
along with a firm belief that good health should 
be a right for all Tennesseans, represents the 
philosophy underlying all of our work. As a 
specific expression of these principles, we should 
insure that every child is given the right to be 
born healthy, that the piovision of quality health 
care not be dependent upon a person’s ability 
to pay, and that all people are provided con- 
tinuous health education. 

We believe federal, state, and local health 
agencies (private, public, and voluntary) should 
initiate a continuing public education program 
to promote good health and provide informa- 
tion in the availability and utilization of health 
services. 

Medical care should be comprehensive and 
should place most importance on prevention; 
therefore, primary consideration in the plan- 
ning and allocation of health resources should 
be given to prevention of disease, disability, and 
premature death. Where health services are 
needed, but are unavailable, inaccessible, in- 
adequate, or insufficient, it should be the re- 
sponsibility of local, state or federal govern- 
ment to provide such services. 

We recognize the importance, the challenge, 
and the opportunity to express concern for all 
people through comprehensive health planning. 
We feel, however, that most people are not 
fully aware of the existence of comprehensive 
health planning nor do they understand the 
benefits they can derive from its implementa- 
tion. Therefore, we, the Tennessee Health 
Planning Council, should provide information 
and publicity about the health care system. 
We should also encourage support of needed 
legislation identified as contributing to the 
realization of desirable long-range health goals. 
Also, in this connection, we should set forth 

^Report of Task Force on Health Goals. Tennessee 
Health Planning Couneil. 


target dates for significantly reducing incidence 
rates for preventable conditions; e.g., tubercu- 
losis, venereal disease, deaths from cancer of 
the cervix. 

While the implementation of this counsel 
will require actions of a regulatory nature, we 
are of the opinion that we have a vital function 
to perform and can best serve the interest of 
the public by striving to remain a nonregulatory 
and independent body. 

The study and appropriate implementation of 
these recommendations and the day-to-day di- 
rection of the health planning process and ac- 
tivities are the responsibility of the director 
and staff of the Tennessee Office of Compre- 
hensive Health Planning. 

The staff shall give top priority to planning 
and to activities relating to planning. Program 
atcivities, such as Phase II Cost Control, Na- 
tional Health Service Corps, Medical Experi- 
ence Directed Into Health Careers, shall be 
given secondary priority and accepted only as 
additional resources permit. 

Ideally, the staff shall base its planning ac- 
tivities on gathering and analysis of facts, tech- 
nology available to target on the problem/ 
issue, and consideration of the quality of plan- 
ning being performed by other agencies. Timing 
and cost shall be less important factors that 
determine the need for planning. Least im- 
portant factors are: pressure from vested inter- 
est power sources, availability of funds, what 
people “think” is needed, and what the staff 
“wants.” 

Furthermore, the staff shall strive for excel- 
lence in planning. All plans must be supported 
with background information and accurately 
documented. In implementing plans, the staff 
shall include educational efforts and public 
information methods to influence improved 
changes in health as well as changes in per- 
sonal behavior and attitudes. 

In addition, the staff and council shall en- 
courage the consumer’s active participation in 
health planning. Comprehensive health planning 
is an advocate of all consumers and providers 
interested in planning for improvement in the 
health care delivery system. 

We believe continuity of health care should 
be assured for patients entering any point in 
the health care system and that primary, am- 
bulatory care should be the preferred method 
of health care delivery. Secondary, institutional 
care should only be utilized for health services 


m. 


/pccicil 
item 


k t UL s wwt. \ ui 


and Policies* 



264 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


that cannot be delivered on an ambulatory basis. 
In this connection, in-patient bed facilities and 
services should be constructed or expanded 
only if community need clearly requires it. 

The health care delivery system should con- 
sist of a variety of methods of delivery, includ- 
ing, but not limited to, prepaid group practice, 
family health centers, neighborhood health cen- 
ters, hospital-based satellites, medical school 
centers, physician groups, fee-for-service solo 
practitioners. However, in the planning process, 
the Tennessee Office for Comprehensive Health 
Planning shall evaluate experimental as well as 
the existing methods of health delivery. 

We are convinced that a complete system of 
emergency medical services is necessary and 
should be made available to all people. 

The staff should assure that family planning, 
mental health, and rehabilitative services are 
considered and receive special attention in their 
planning efforts. We believe that family plan- 
ning should be made available to all citizens, 
that mental health services be available and 
accessible at the community level, and that re- 
habilitative services be available to all physically 
and mentally handicapped. 

The demand for health services has out- 
stripped the capability of health manpower to 
deliver these services. We, therefore, rec- 
ommend that wherever possible, functions phy- 
sicians and dentists now traditionally perform 
be delegated to allied health personnel. In 
addition, incentives should be provided to en- 
courage health professionals, trained in Ten- 
nessee, to remain to practice their profession 
in Tennessee. 

With respect to professional health personnel, 
we recommend that provider groups use ap- 
propriate methods of peer review to prevent 
development of conflict of interest situations 
in which the patient is exploited, and assure 
high quality health care at reasonable, afford- 
able costs. 

Finally, we believe that environmental 
quality is a fundamental aspect of health and 
should be a major consideration of this Council 
and the Tennessee Department of Public Health. 
On a statewide basis, the general distribution 
and density of population and the uses to which 
we put our land are key factors. In comparison 
with some of the more heavily populated parts 
of our country, Tennessee is, at present, an 
underpopulated state. Considering the wealth 
of natural beauty of Tennessee and its great 


potential for industrial development, we should 
anticipate an accelerated growth rate as popula- 
tion pressures continue to mount in the great 
urban centers to the north and northeast of us. 
This suggests that portions of Tennessee now 
considered rural and which may have no wide- 
spread environmental problems today, may be- 
come increasingly more at risk. In this connec- 
tion, and in preparation for rational land-use 
planning, we encourage the design and funding 
of systems studies to determine the optimum 
population growth patterns for Tennessee. 

On a local basis, we recognize that social 
conditions have a direct effect on health. Conse- 
quently, we recommend that attention be di- 
rected to the social needs of all our population 
for a clean, safe, and enjoyable environment, 
adequate housing, nutritional education, trans- 
portation, recreational facilities, and mutual re- 
spect. Many of these general goals can best 
be attained by identifying specific actions to be 
taken, and by setting desired time limits. In 
this regard, we recommend that all public 
water systems be fluoridated and that a date 
should be established when this is to be ac- 
complished. 


WHITE SURGICAL SUPPLY CO. 

1921 52 Years 1973 

Service to 


PHYSICIANS AND HOSPITALS 


Owner Operated 

DISTRIBUTORS 

of Quality Products 

EQUIPMENT— INSTRUMENTS 
—SUPPLIES 


White Surgical Supply Co. 

127 Bearden Place, N.E. 

Knoxville, Tennessee 
Phone 546-3701 


MARCH, 1973 


265 



Wm. T. Satterfield 


National Health Plans — 1973 

A new Congress, with some new faces and some old issues, had hardly 
convened before about 2,350 proposals were introduced, of which 375 
were of interest to medicine. Among these were H.R, 1, introduced 
by Rep. Ullman (D-Ore.), a National Health Insurance Program based 
upon the American Hospital Association’s “Ameriplan” proposal. It is 
a new system of health care delivery designed to provide both basic 
and catastrophic coverage to all persons at a cost related to income, 
primarily through groups centered around hospital staffs. 


pfc/icIcfilV 

pQ9C 


Sen. Kennedy and Rep. Griffiths reintroduced S. 3 and H.R. 22 as 
their National Health Plan, modified from last year. HMO’s are featured 
and funds for training health-care personnel are provided, as well as 
provisions for the settlement of malpractice claims. The cost — ??? (over 
80 billions extra per year!) and direct government control. 


On January 18, Medicredit, the AMA developed national health 
proposal, was introduced (S. 444 and H.R. 2222). It is officially titled 
the “Health Care Insurance Act of 1973.” This bill has broader benefits 
than the similar bill of 1972. Senators Hansen (R-Wyo.) and Harke 
(D-lnd.) and Representatives Fulton (D-Tenn.) and Broyhill (R-Va.) 
are sponsors. Rep. Fulton predicts 200 sponsors in the 93rd Congress. 

Hearings will be held on these bills (and others) this year, although 
predictions for passage for a National Health Plan bill are for 1974. 


Contrary to a prevailing attitude, that “AMA never does anything,” 
this bill is one practicing physicians could live with and be stimulated 
to continue exerting their efforts to elevate the quality of medical care. 

Medicredit is based on the principle of tax credits to help finance 
the purchase of high quality health insurance for everyone. The lower a 
family’s income, the greater the government’s financial assistance. For 
those Americans who pay little or no income tax, the government will pay 
all of their health insurance premium. As income tax liability goes up, 
the extent of the government’s assistance decreases. To encourage all 
Americans to buy health insurance, some government assistance would be 
given all taxpayers. This is the fair way of distributing the high costs of 
medical care — on the basis of each American’s ability to pay. 
Catastrophic coverage is included. The Medicredit Plan assures care 
for all and preserves the private enterprise method in the delivery of 
Health Care. 

It behooves every practicing physician to study Medicredit. If you 
like what you see, tell your national representatives. Perhaps they, too, 
would agree that this is the method of preventing a disruption of the 
health care delivery system that might give American patients inferior care. 

The AMA never does anything??? 


Sincerely, 







President 



joumcil 

OF THE 

TENNESSEE MEDICAL ASSOCIATION 
PUBLISHED MONTHLY 

DEVOTED TO THE INTERESTS OF THE MEDICAL 
PROFESSION OF TENNESSEE 

OFFICE OF PUBLICATION, 112 LOUISE AVENUE, 
NASHVILLE, TENN. 37203 

JOHN B. THOMISON, M.D., EDITOR 

ADDISON B. SCOVILLE, JR., M.D., ASSOCIATE EDITOR 


Acceptance for mailing at special rate of postage provided 
for in Section 1103, Act of October 3, 1917, 
authorized July 15, 1932. 


Copyright for protection against republication. Journals 
of the American Medical Association and of other 
state medical associations may feel free to quote 
from this Journal whenever they desire 
merely giving credit to this publication. 


Address papers, discussions and scientific matter to 
John B. Thomison, M.D., Editor, P.O. Box 70, 
Nashville, Tenn. 37202 

Address organizational matters to Jack E. Ballentine, 
Executive Dir., 112 Louise Avenue, Nashville, Tenn. 37203. 

COMMITTEE ON SCIENTIFIC AFFAIRS 
HARRY A. STONE, M.D., Chairman, Chattanooga 
R. L. DeSAUSSURE, M.D., Memphis 
JOHN H. BURKHART, M.D., Knoxville 
HARRISON J. SHULL, M.D., Nashville 
CHARLES E. ALLEN, M.D., Johnson City 
JOHN B. THOMISON, M.D., Nashville 


MARCH, 1973 


e<IKori<il 


Comprehensive Health Planning 

Printed as a special item in this issue (page 
264) is the Report of the Task Force on Health 
Goals of the Tennessee Health Planning Council. 
This report has been adopted as official policy 
by the Council as a guide for the health plan- 
ning efforts of the Office of Comprehensive 
Health Planning of The Tennessee Department 
of Public Health. I hope you will take the time 
to read it, because it vitally affects you. You 
should know that the task force was made up 
of 15 people, 3 of whom are practicing phy- 
sicians and members of the TMA Committee 
on Comprehensive Health Planning. 

I read the report with a mixture of interest, 
delight, and dismay. It tends to pontificate, 
but sets forth some noble goals. What bothered 
me most was what appeared to be some fuzzy 
thinking and imprecise terminology, which lead 
to some unfortunate implications. 


The report starts off by claiming good health 
(not health care) as a right for all Tennesseans, 
and that it is the right of every child to be 
born healthy. Unless we are going to do a lot 
of genetic dickering, it is no more possible for 
every child to be born healthy than to be born 
good looking, and we all know about that 
(also, mothers often do things which they know 
to be harmful to the fetus, such as using drugs.) 
As for health as a right, I refer you to a previous 
editorial (Vol. 65, p. 731, Aug. 1972), and 
will only say here that when people continue to 
gorge themselves, smoke, and drink and drive 
(among other things) in the face of all the 
evidence (and it isn’t for lack of education) — 
how can good health be considered a right? 
If the report means that everyone has a right 
to good health care, we’ll talk about that later. 
If it means what it says, forget it! A goal, 
yes. But not a right. 

Which brings me to my second point: health 
care does not equal medical care, and I am 
not always sure which is meant in the report. 
The report says “Medical care should be compre- 
hensive, and . . . primary consideration . . . 
should be given to prevention of disease, dis- 
ability, and premature death.” And I say, “Right 
on.” But the biggest part of prevention is not 
medical at all, but social, and has somewhat 
to do with public education (which is laudably 
emphasized in the report), but even more to do 
with individual responsibility. It has to do with 
spiritual resources, with self discipline, and with 
character. To carry out this most important 
aspect of prevention is going to cost somebody 
— everybody — and not just money. 

The biggest cause of preventable death and 
destruction is the gasoline engine sailing down 
the concrete strip, particularly if the gasoline 
is mixed with alcohol. Some of the vehicles 
are unsafe at any speed. I refer you to another 
editorial about this last month. But will you 
hold still for a law requiring that your auto- 
mobile be inspected semiannually, that you have 
a physical examination biannually, for teeth in 
the law, with roadblocks to enforce it? And 
will you go to jail for driving if you drink? 
(You will in some parts of Europe — they are 
taking this seriously.) We can virtually elimi- 
nate highways deaths, if we are willing to pay 
the price. To place the responsibility on the 
automobile manufacturers begs the issue. 

And will you stop smoking so you won’t get 
emphysema, ulcers, cardiovascular problems. 


MARCH, 1973 


267 


oh, yes, lung cancer? How about not eating 
so much, so you won’t get an early coronary 
occlusion or diabetes. (All this applies to doc- 
tors, too, who of all people should know better.) 

Let’s get straight what we’re talking about 
when we talk of preventing disability and pre- 
mature death. Mostly, people talk about what 
someone else (usually doctors) can do for them 
(tuberculosis, V.D., or cervical cancer — and 
this is not unimportant.) But they can do a 
lot more for themselves — and will not. Again, 
it’s not because of ignorance. 

Now let’s talk about the right to quality health 
(medical?) care at reasonable, affordable cost. 
No one wants this for his patients more than 
the physician. But the report contains two 
mutually exclusive statements. One is that 
everyone deserves high quality care, and the 
other is that wherever possible functions tra- 
ditionally performed by physicians and dentists 
be delegated to allied health personnel. Really, 
they can’t have it both ways. What we’re really 
talking about is a compromise. The “feldsher” 
system has been tried many times before, and 
is in use extensively in Russia and China. It is 
an attempt to make some sort of medical care 
available in underserved areas. No one in those 
countries claims it is as good as having a doctor 
there. It is, however, a satisfactory compromise. 
We physicians, as well as the planners, are going 
to have to face this fact. 

Medicine has become very sophisticated and 
complex. The high cost of medical care is due 
least of all to physicians’ fees. There are pro- 
cedures available which nobody can afford. 
What is a reasonable cost? And where does 
one stop? A few years ago renal dialysis was 
available to only a few. Now it is available to 
pretty much anyone who needs it. But before 
small portable units were available and relatively 
inexpensively produced, there was no way — I 
repeat, no way — regardless of expense (which 
was extreme), to make it available to everyone, 
it is part of the nature of medical progress that 
this will always be so. The logistical and eco- 
nomic problems are insurmountable. Therefore, 
a reasonable cost is not necessarily affordable. 

I particularly cheered the last two paragraphs. 
If there is one thing I dislike above anything 
else that is happening to my environment, it 
is sitting in a meeting, or enjoying a meal in a 
restaurant, only to have cigarette smoke (or 
worse still, cigar or pipe smoke) wafted into 
my nostrils. Not only is it unpleasant, but 

263 


the surgeon general says it is dangerous to my 
health (not my smoke — yours). While every- 
one is talking about industrial pollution, etc. 
(which is fair game) will we, as individuals, 
stop our own polluting habits? (I don’t smoke, 
but my car does.) Next month the whole issue 
will be devoted to this subject. 

As you read the report, you will find things 
you do and do not like about it. I have listed 
a few of mine — there are others, on both sides. 
Some that 1 passed over here are more than a 
little frightening because of bureaucratic over- 
tones. But the Task Force, and the Council, 
have recommended that the policy statement 
be subject to continuing study and annual re- 
vision. Make your thoughts known to your 
TMA committee, through which you have in- 
put into the Council. 

A final word: The report talks about the 

patient’s rights. We physicians talk about our 
rights. Everyone is talking today about his 
rights. I have tried to indicate that a workable 
society depends on individual responsibility, 
and that we all have to give up some rights 
in order to ensure others. Often society must 
decide which right takes pre-eminence. We may 
not like the decision. Society is more and more 
decreeing that it is my right not to have smoke 
blown in my face. But it is also saying I must 
stop my car from smoking, and I may have 
to find some other way to get rid of my leaves. 
God help us if we ever reach the point where 
everyone stands on his own individual rights 
every time! 

J.B.T. 



To the Editor. The anachronistic editorial 
“Darwin Revisited” which appeared in the 
December 1972 issue of the JTMA is earnestly 
in need of rebuttal. The author writes as though 
he were living in the 1 8th century. The theory 
of evolution is as well proven and documented 
as is the germ theory of disease. Tremendous 
amounts of fossils, artefacts, skeletal remains, 
weapons and tools dating back several million 
years have been found. These items have very 
well filled in the “missing links” first referred to 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



over a century ago. All of this is disposed of 
as “an occasional jaw bone, skull fragment, or 
a few teeth scattered here and there.” Over 
100 specimens of Neanderthal and 20 specimens 
of Homo erectus have been found and described. 
In addition, the immediate ancestor of man, 
Australopithecus (man-ape and ape-man) with 
their weapons and relics have been uncovered 
and adequately described in recent decades. It 
is only necessary to visit any library and review 
a modern textbook of biology or persue the 
works of Leakey, Broom, Dart, Coon, Clark, 
Howells. Weidenreich, Simpson and many others 
to realize the scope and depth of this work. 
All of this has the more firmly established 
Darwin as the giant he really was. None has 
detracted in any way. The great Isaac Newton 
said that if he had seen farther it was because 
he had stood on the shoulders of giants. The 
author of this editorial would appear to be 
standing in a deep ditch. The entire science 
of biology is firmly based on evolution. 
Haeckel’s biogenetic law states that “ontogeny 
recapitulates phylogeny.” Evolution forms the 
foundation and rationale for any worth while 
study of biology, embryology or anatomy. 

The ignorant man believes what he wants to. 
He doesn't like to be confused by facts. He 
is intellectually lazy and refuses to be confused 
by any e\idence which dedicated men have 
labored a lifetime to produce. The scientist 
accumulates all the data possible and then forms 
his theory. If new data makes the theory un- 
tenable he does not reject the new facts but 
incorporates them into a revised theory. Dar- 
win’s Origin of the Species and Descent of Man 
has stood the test of time very well; the vast 
amount of data accumulated since it was first 
published in 1859 has strengthened it. No 
flaws have been uncovered. Darwin gave an 
estimate of about 1,000,000 years as the time 
needed for a new species to be established. This 
is referred to by the editor as “crossing over.” 
It is very puerile for any one to expect to see 
this happen in a few decades or centuries. 

The material upon which the Theory of Evo- 
lution rests is to be found in many museums 
throughout the world. Innumerable fossils have 
been tested by radioactive dating and found 
to be from a few thousands to many millions 
of years old. 

In contrast to this; where are the facts, the 
fossils, the relics to document the theory of 
sudden creation? If this really happened as 


recently as 6000 years ago, the proponents of 
this theory would have by this time accumulated 
a vast store of material evidence and should 
have established a scientific basis to support 
their theory. If they cannot do this, and to date 
they have not, they should not “bad mouth” a 
great man who spent many years of study and 
work to accumulate a vast collection of facts 
which firmly establishes evolution as the only 
hypothesis to fit the observed and recorded data. 

The editor apparently prefers to put his “blind 
faith” in sudden creation rather than evolution. 
The ignorant man is proud of his “blind faith.” 
The intelligent prefers to maintain an open mind 
and use that mind to study, to review the data, 
to carefully consider the fossil evidence and to 
choose the theory that is based on science. 

B. C. Collins, M.D. 

3144 Summer Ave. 

Memphis, Tenn. 38112 

Editor’s note'. As the author of the editorial 
“Darwin Revisited,” and editor of the JTMA, 
I am happy to publish in its entirety Dr. Collins’ 
communication concerning that editorial, with 
some further comments of my own, taking the 
editor’s prerogative. As background to these 
comments, I should say that archaeology, ge- 
ology, anthropology and paleonthology have 
been my hobbies for over 30 years. I have an 
extensive library on those topics, a large col- 
lection of fossils, and many photographs. I 
have spent countless hours m museums of 
natural history. I shall assume that Dr. Collins 
has as carefully studied the many aspects of 
creation. 

It is an unfortunate oversimplification to 
divide people into creationists and evolutionists, 
because there has been a vast amount of non- 
sense written on both sides of the issue. “Evo- 
lutionists” ascribe to the superb naturalist, 
Charles Darwin, and to others things they never 
said, while “creationists” misquote and mis- 
construe the Biblical account of creation. To 
say that the entire universe was created in the 
week of October 28, 4004 b.c. is contrary 
not only to reason, but to the Bible itself (the 
Bible being an imminently reasonable and prac- 
tical book). The Hebrew word “day” used in 
Genesis can as easily be translated (and is else- 
where) “era” or “age,” and there is nothing 
in it to preclude man’s having been on the earth 
a million years (or 2.6 million, as Dr. Leakey’s 
latest find suggests). 


MARCH, 1973 


269 


As for the “generations of Adam,” from 
which the date 4004 b.c. was calcuiated by 
Bishop Usher, nowhere does the Bible intimate 
that genealogy equals chronology, and if one 
studies the scripture carefully, he finds it is 
customary to leave out generations, and in 
places hundreds of years, so that the term 
“son of” means only direct descendent, and 
“begat” means one was progenitor of the other. 
The Hebrew concept (and one with which it 
would be difficult to quarrel) was that the 
entire Hebrew race was in “Abraham’s loins,” 
so any of his descendants could be considered, 
and referred to, as his son, or that Abraham 
“begot” him. 

On the other side, recent finds by Dr. Richard 
Leakey, far from shoring up the evolutionists’ 
arguments, have cast serious doubts on them, 
and his own statement concerning his 2.6 million 
year old hominid with a brain as large as that 
of modern man is that “it is something outside 
the continuous one line descent of man in 
which Australopithicus gradually develops into 
Homo erectiis.” Dr. F. Clark Howell, professor 
of Anthropology at the University of California 
at Berkeley, has stated that it appears “there 
may have been many different manlike creatures, 
some much more human than others, which was 
not known before. Australopithicus may be out 
of the picture as an ancestor of man.” 

You have only to read these and other com- 
ments concerning these finds fo realize how un- 
sfable is the fact base from which we operate 
as scientists. Regardless of our position, the 
creation of matter and of life itself resists 
explanation except by creation “ex nihilo.” This 
is an area in which the reason of finite man is 
limited. The Biblical account of creation is not 
contrary to science, as geologists who have 
taken the trouble to study carefully the Genesis 
account have stated very clearly. 

Space does not permit detailed documentation 
of flaws in the evolutionary theory, but they are 
numerous and, as stated previously, were rec- 
ognized by Darwin. The majority of the sci- 
entific community has never faced these flaws, 
and many are not aware of them. Many of 
the most distinguished geologists and paleontol- 
ogists, however, recognize that they exist, and 
have documented them, whichever position they 
happen to support. Several have written books 
explaining their preference for the Biblical ac- 
count. (Lack of space precludes publishing 
either Dr. Collins’ or my reference list, which 

270 


may be obtained by writing this office.) Even 
Sir Julian Huxley, Darwin’s greatest champion, 
had the frankness to state that naturalistic evo- 
lution reigns unchallenged not because it has 
been proved, but because “the only alternative 
is clearly unacceptable.” The alternative? Belief 
in creation, which presupposes a Creator. 

Dr. Collins seems to have missed the point 
of the editorial, which was not to support the 
Creation theory as provable, but to show that 
there is a valid alternative to the evolutionary 
theory, that neither position is provable, and 
that acceptance of either is based on a certain 
degree of faith. The ignorant, he says, are 
proud of their “blind” faith. Faith is blind 
only insofar as we are ignorant, but we would 
do well to recognize how ignorant as scientists 
we all are, and are likely to stay, in these 
matters. While it is possible to take members 
of the Flat Earth Society into space and show 
them that the world is in fact round, there is 
no way yet available to journey back in time 
and witness either the creation or evolution of 
man. Any such theory is based on certain 
unprovable presuppositions. Some prefer to 
ascribe omniscience and omnipotence to God; 
others, such as Jacques Monod, to Chance. 

The Bible has stood the test of time at least 
as well as Darwin’s theory, and much longer. 
Truth is truth, and one truth never contradicts 
another. As scientists, our work is to search 
for truth, and to recognize a theory for what 
it is. 

Dr. Collins, welcome to the ditch! 

John B. Thomison, M.D. 



CATE, WILLIAM ROBERT, Nashville, died January 
19, 1973, age 79. Graduate of Emory University, 
1920. Member of Nashville Academy of Medicine. 

CHAMBERS, JOHN MANN, Memphis, died January 
15, 1973, age 59. Graduate of University of Tennessee 
School of Medicine, 1936. Member of Memphis- 
Shelby County Medical Society. 

DONALSON, L. M., Eayetteville, died January 31, 
1973, age 72. Graduate of Meharry Medical College, 
1932. Member of Lincoln County Medical Society. 

DUFFY, RICHARD NIXON, JR., Knoxville, died 
January 16, 1973, age 58. Graduate of Johns Hopkins 
School of Medicine, 1940. Member of Knoxville 
Academy of Medicine. 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


GARROTT, WILLIAM A., Cleveland, died lanuary 
18, 1973 at age 72. He was a graduate of Vanderbilt 
University School of Medicine Class of 1926. Member 
of the Bradley County Medical Society. Dr. Garrott 
had just been notified by the Tennessee Medical Asso- 
ciation that he had been named the recipient of the 
1972 Distinguished Service Award which would have 
been presented to him at the Annual Meeting in 
Memphis. 

HARRIS, HERSCHEL BARLOW, Chattanooga, died 
January 19, 1973, age 48. Graduate of Medical Col- 
lege of Alabama, 1953. Member of Chattanooga- 
Hamilton County Medical Society. 



The Journal takes this opportunity to welcome these 
new members of the Tennessee Medical Association. 

GILES COUNTY MEDICAL SOCIETY 

Armando C. Foronda, M.D., Pulaski 
William P. Titus, III, M.D., Pulaski 

KNOXVILLE ACADEMY OF MEDICINE 

Monte B. Biggs, M.D., Knoxville 
John T. Bushore, M.D., Knoxville 
Martha S. Bushore, M.D., Knoxville 
William W. Cloud, M.D., Knoxville 
Joseph C. DeFoire, Jr., M.D., Knoxville 
C. S. Albert Ebenezer, M.D., Knoxville 
Charles W. Godwin, M.D., Knoxville 
Milbrey Hinrichs, M.D., Knoxville 
Michael Howe, M.D., Knoxville 
Harold E. Kerley, M.D., Knoxville 
Fred A. Killeffer, M.D., Knoxville 
Rodger P. Lewis, M.D., Knoxville 
Thomas H. Lowry, M.D., Knoxville 
Edward M. Malone, M.D., Knoxville 
John H. L. Marshall, M.D., Knoxville 
Cynthia McMillan, M.D., Concord 
Stephen E. Natelson, M.D., Knoxville 
William A. Robinson, II, M.D., Knoxville 
Norman H. Rucker, M.D., Knoxville 
Alex Ruth, M.D., Knoxville 
Ronald K. Sandberg, M.D., Knoxville 
C. Gerald Sundahl, M.D., Knoxville 
Emilio Verastegui, M.D., Knoxville 

MAURY COUNTY MEDICAL SOCIETY 

James M. Fitts, M.D., Columbia 

MONROE COUNTY MEDICAL SOCIETY 

James Lester Allen, M.D., Sweetwater 

NASHVILLE ACADEMY OF MEDICINE 

Jacinta J. Llorens, M.D., Nashville 
Stephen P. Melkin, M.D., Nashville 
Mona K. Mishu, M.D., Nashville 

SULLIVAN-JOHNSON COUNTY 
MEDICAL SOCIETY 

William J. Boyd, M.D., Bristol 


Locke Y. Carter, M.D., Kingsport 
Malcolm E. Rogers, M.D., Kingsport 
Frank S. Sikora, M.D., Bristol 
Robert C. Taylor, M.D., Bristol 


pf09iam/ <md neui/ of 
fiieclkcil /odelic/ 


Chattanooga-Hamilton County 
Medical Society 

The Society held its annual President’s installation 
banquet on January 16 at the Read House. Newly 
elected 1973 officers were installed including Dr. 
Charles Alper, President; Dr. Lee Arnold, President- 
Elect; Dr. Paul Hawkins, Secretary-Treasurer. 

Memphis-Shelby County Medical Society 

The Society held its regular session on February 6. 
The Scientific Program included Dr. E. E. Muirhead, 
Professor of Pathology and Clinical Professor of 
Medicine at University of Tennessee Medical School 
who spoke on the topic “The Antihypertensive Func- 
tion of the Kidney.” 

Nashville Academy of Medicine 

Officers for the Davidson County Foundation for 
Medical Care include Dr. John Farringer, President; 
Dr. Thomas Zerfoss, Jr., Vice-President; Dr. Dan 
Sanders, Secretary-Treasurer; and Dr. Fred Rowe, 
Assistant Secretary-Treasurer. 

Dr. Hern Bradley, Dr. John Burch, and Dr. R. H. 
Kampmeier have qualified for the TMA’s 50 year 
award which will be presented at the TMA Annual 
Meeting in April. 

John Westenberger assumed the position of Executive 
Director of the Academy effective February 1. 


iKiliofiol ncui/ 


THIS MONTH IN WASHINGTON 
(From Washington Office, AMA) 

The American Medical Association protested 
vigorously against President Nixon keeping 
physicians under federal regulation in Phase 
III of the economic controls program. 

A largely voluntary set of wage-price con- 
trols was substituted for all segements of the 
nation’s economy except food, health care ac- 
tivities, the construction industry, and interest 
and dividends. 

John R. Kernodle, M.D., chairman of the 
AMA Board of Trustees warned that such 
discriminatory treatment well could result in 
health care support personnel leaving the field. 


MARCH, 1973 


271 






Physicians, he said, could not be expected to 
accept it. 

“Controls are relaxed in other areas, yet the 
discrimination against physicians and some three 
million others who serve America’s health needs 
is now even more sharply focused,” Dr. Kern- 
odle said in a statement. “A very real possi- 
bility exists that there will be a flight of allied, 
ancillary and support personnel from the health 
field, jeopardizing the quality of care being 
delivered.” 

Dr. Kernodle pointed out that, “even though 
the regulations as applied to health care were 
clearly discriminatory,” the AMA had urged 
physicians to cooperate and they had done so 
with a result that their fees nationwide had 
increased by only 2.7 per cent since August, 
1971, when Phase I began. This compared 
with 4.3 per cent for the consumer price index, 
6.2 per cent for a semi-private hospital room, 
and 14 per cent for legal services. 

Noting that controls never were imposed on 
lawyers or other self-employed professionals, 
he said that physicians now might have to re- 
consider their attitude of cooperation. 

“Since its inception, we in medicine have 
made every effort to cooperate with the gov- 
ernment’s program,” Dr. Kernodle said. “While 
the Lords of Labor walked out, we remained in 
the program and tried to make it work in the 
public interest. The results speak for them- 
selves. 

“We have received very little cooperation in 
return. . . . 

“Thirteen months ago, we urged physician 
compliance. In light of the . . . record, we 
shall now have to reconsider that advice.” 

Dr. Kernodle later took the AMA protest 
directly to President Nixon in a letter. It 
follows; 

Dear Mr. President: 

The American Medical Association has ap- 
plauded your Administration’s efforts to stabi- 
lize prices and wages for the economy. The 
Association has supported the overall objectives 
of the Economic Stabilization Program and 
actively cooperated with the Cost of Living 
Council through the Health Services Industry 
Committee in the application of price controls 
on physicians’ fees. 

A look at the physician component of the 
Consumer Price Index gives an example of the 
effect that “voluntary compliance” can have 
in curbing inflation. As a result of this Associ- 

272 


ation’s activities, physicians’ fees rose only 
1.7% under Phase II. This constitutes one- 
third the rate of increases prior to the Economic 
Stabilization Program. In this respect, we 
have surpassed the original expectations of the 
Cost of Living Council, which called for halving 
the inflationary rates prior to Phase I. 

In view of our demonstrated success during 
the past year, you can imagine our dismay at 
the announcement of plans for Phase III. Al- 
though most of the economy is now expected 
to “voluntarily” adhere to the general guide- 
lines of the Cost of Living Council, the medical 
profession has been placed under mandatory 
regulations. Indeed, the medical profession has 
once again been singled out under special con- 
trols. The physicians of America will not ac- 
cept such discriminatory treatment. This pro- 
fession must not become the victim of efforts 
to curb inflation in the more expensive com- 
ponents of the health care industry, which due 
to their internal financial structure have been 
unable to decelerate increases in their prices. 

The record of the past year clearly dem- 
onstrates that physicians are able to effectively 
control their fees through voluntary action. 
The record of the past year is equally clear 
that physicians’ fees have not been an inffa- 
tionary factor in health care costs. We, there- 
fore, request that the medical profession be 
exempt from special regulations under Phase 
III, and respectfully request an early oppor- 
tunity to visit with you on this and other matters 
of critical importance to the nation and the 
medical profession. 

^ ^ 

Some 126 senators and congressmen have 
introduced an improved and expanded version 
of the American Medical Association backed 
Medicredit bill for national health insurance. 

Based on the principle of using tax credits 
to spur the purchase of comprehensive health 
insurance for all Americans, the Medicredit 
proposal has four chief bipartisan sponsors — 
Sens. Vance Hartke (D-Ind.) and Clifford 
Hansen (R-Wyo.), both of the Senate Finance 
Committee, and Reps. Richard Fulton (D- 
Tenn.) and Joel Broyhill (R-Va.), both of 
the House Ways and Means Committee. 

Russell B. Roth, M.D., AMA’s president- 
elect, joined the chief sponsors of the proposed 
legislation after its introduction into the Con- 
gress at a Capitol Hill press conference and 
detailed the new provisions of Medicredit 1973 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


which include dental care for children, emer- 
gency dental care for all ages, and improved 
home health services. 

Dr. Roth said that the new Medicredit pro- 
posal should cost about $12.1 billion, approxi- 
mately the same as last year’s bill. He pointed 
out in explanation, however, that while new 
benefits have been added to the 1973 version, 
certain modifications had been made to the new 
bill’s deductible and coinsurance features. 

The Medicredit bill is a three-ponged ap- 
proach to providing health insurance protection, 
according to Dr. Roth. The proposal would: 
— pay the full cost of health insurance for 
those too poor to buy their own, 

— help those who can afford to pay a part 
of their health insurance cost. The less 
they can afford to pay, the more the gov- 
ernment would pay, 

— see to it that no American would have 
to bankrupt himself because of a catastro- 
phic illness. 

On the subject of the catastrophic provisions 
of the bill, Hartke said: 

“1 have been appalled, as have most of us, 
by the medical horror stories that have been 
brought to our attention. Hardly a week passes 
without news of yet another family pauperized 
by catastrophic illness. . . . 

“Under Medicredit, the tragedy of cata- 
strophic illness would no longer be worsened 
by the threat — or the actuality — of financial 
catastrophe. No American family would ever 
again face the prospect of losing its savings, 
or its home, or its solvency because of health 
or medical bills.” 

Broyhill compared the Medicredit bill with 
other national health insurance proposals in 
the Congress. 

“According to a report prepared for the 
House Ways and Means Committee during 
the last session, the Kennedy-Griffiths proposal 
would have cost the taxpayers a staggering $91 
billion a year,” he said. “This would have 
meant that health alone took up about one- 
third of the entire Federal budget. . . 

“Rich or poor, everyone under this proposal 
would have Uncle Sam pay all or most of his 
health care bill every year. 

“The Medicredit proposal, on the other hand, 
is designed to spread the cost of medical and 
health care fairly and equitably over the popu- 
lation on the basis of each American’s ability 
to pay.” 


Stating that Medicredit is designed to solve 
the most immediate and pressing problems of 
the nation’s health care system, Hansen empha- 
sized that the AMA plan would “unlock the 
financial doors that bar many Americans from 
high quality medical care . . . stress preventive 
care — annual check-ups, out-of-hospital diag- 
nostic services, well baby care, dental care 
for children, and home health services . . . pro- 
vide psychiatric care without limit. . .” 

Predicting that Medicredit would wind up 
with 200 sponsors in the 93rd Congress . . . 
25 more than in the 92nd . . . Fulton noted 
that a third of the sponsors were Democrats, 
which establishes the AMA-backed bill as the 
national health insurance proposal with the 
most bipartisan support. 

“What this bill’s sponsors are endorsing,” 
Congressman Fulton said, “is an approach to 
the problem of financing health care. What we 
are all saying, I think, is that we do not be- 
lieve that the federal government can — or 
should — assume the entire burden by itself; 
that we should build on what we have instead 
of junking it and starting out again from 
scratch; and that the government role should 
be confined to that of helping those who need 
help. . .” 

^ 

President Nixon plans to end the 26-year-old 
Hill-Burton program of federal grants for hos- 
pital construction and the regional medical pro- 
gram. His fiscal 1974 budget also calls for 
cutbacks in programs for community health 
centers, children’s mental health and alcoholism. 

Under the budget, medicare patients would 
have to pay an additional estimated $1.2 billion 
of their hospital and medical bills in the next 
18 months. 

Aside from medicare outlays of $12.6 billion, 
the federal budget for health — most of it under 
the Department of Health, Education and Wel- 
fare — calls for expenditures of $9.1 billion in 
the 12 months, an increase of $700 million over 
the current fiscal year which ends June 30. 

Some National Institutes of Health research 
programs would be cut back but spending on 
cancer would climb $91 million to $445 million, 
and outlays on heart and lung diseases would 
increase $28 million, to $250 million. Special 
emphasis would be placed on those types of 
cancer that cause the highest mortality — lung, 
breast, large bowel, prostate, bladder and pan- 
creas. Heart research would focus on prevent- 


MARCH, 1973 


273 


ing arteriosclerosis and hypertension. 

The NIH program of support for training of 
research scientists — now $150 million a year — 
would be discontinued. The federal government 
also would reduce its support for training 
nurses, veterinarians, optometrists, podiatrists, 
pharmacists and public health personnel. Fed- 
eral support would be concentrated on training 
of physicians and dentists. 

President Nixon’s plans for cutbacks in some 
health expenditures were foreshadowed by two 
vetoes of HEW appropriation bills last year. 

“My strategy for health in the 1970s stresses 
a new federal role and basic reforms to assure 
that economical, medically appropriate health 
services are available when needed,” he said 
in his budget message. 

An HEW official described the cutbacks as 
“a conscious decision to identify those programs 
that have fulfilled their purposes already or are 
unable to.” HEW officials said the regional 
medical program, which initially was designed 
to combat heart disease, cancer and strokes, 
never achieved its goal of providing better 
planning of health resources locally or speeding 
research knowledge into therapy. Support 
would be continued for the 515 centers estab- 
lished under the nine-year-old community mental 
health program but funds would not be pro- 
vided to expand the number to the original goal 
of 2,000. 

In the medicare program, the Administration 
is beginning to put into effect non-legislative 
reforms that are estimated to save the govern- 
ment $342 million during the remainder of this 
fiscal year. The President said he will ask Con- 
gress for authority to shift $600 million a year 
in charges to medicare patients. 

The combined effect of the legislative pro- 
posals and administrative actions would be a 
net savings to the federal government in fiscal 
year 1974 of $849 million, according to the 
proposed budget for the Department of Health, 
Education, and Welfare. 

Effective January 1, 1974, if congress agrees: 

— Those who are hospitalized would have 
to pay the first day’s charge for room and board 
and 10 per cent of the charges for all hospital 
services thereafter. As it is now, a medicare 
patient pays $72 — the national average cost of 
one day in a hospital by a medicare beneficiary 
— for the first day of hospitalization and nothing 
more until the 61st day when he begins paying 
$18 a day toward his charges. 


A medicare spokesman said that for a pa- 
tient hospitalized 13 days, the average for bene- 
ficiaries, the cost could increase from $72 to 
a minimum of $158.40. About five million dis- 
abled or aged 65 or older will be hospitalized 
under medicare during the next fiscal year. 

— Under medicare Part B, the voluntary 
doctor insurance that will cover 22.5 million 
persons next year, the patient would pay the 
first $85 of his doctor bills and 25 per cent 
of the remainder. He now pays a $60 deductible 
and 20 per cent of subsequent charges. For a 
patient with a $500 doctor bill, his share of 
the cost would increase from $148 to $188.75. 
About 11.6 million beneficiaries will receive 
medical care during the next fiscal year. 

The Nixon Administration plans to let the 
draft law lapse June 30 for physicians and 
dentists as well as general military personnel. 

In announcing in late January that no more 
draftees would be called up for military ser- 
vice, outgoing Defense Secretary Melvin R. 
Laird urged that congress approve pay incen- 
tives for military doctors, dentists, nurses and 
other health personnel “so that they also can 
be put on a volunteer basis.” This led some 
to infer that physicians and other health per- 
sonnel might be drafted before expiration of 
the draft law. 

But the defense department later gave as- 
surances that it was not planned to call up any' 
more physicians, that Laird only was empha- 
sizing the importance of the pay incentives. 

The draft call for physicians was for 1600 
in late 1972. There now are about 14,000 
m.edical personnel in military service. 


ificclicQl new/ 
in lennc//ee 


An area wide meeting of physicians and 
hospital administrators met recently at the 
Jackson-Madison County General Hospital in 
Jackson to discuss ways and means of attract- 
ing more physicians to the western part of the 
state. Officials from the two Regional Medical 
Programs, Tennessee Higher Education Com- 
mission, Tennessee Department of Public 
Health, Tennessee Medical Association, and 
Tennessee Hospital Assocation were present to 
participate in a panel discussion on what is 


274 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 




being done to improve the physician population 
ratio. 

It was pointed out by Dr, John R. Thomp- 
son, Jr., administrator of Jackson-Madison 
County General Hospital that approximately 
60% of the physicians training in Tennessee 
remain in practice in Tennessee. However there 
is a need for retaining more of the doctors who 
decide to locate outside the state. 


Don H. Alexander Named To 
TMA Executive Staff 



Don H. Alexander 


Don H. Alexander was named Executive 
Assistant and Field Representative of the Ten- 
nessee Medical Association effective February 
1 . 

He previously served as an administrative 
assistant with the Georgia-Tennessee Regional 
Public Health Services centered in Chattanooga. 

A Nashville native, Alexander, 25, received 
the B.S. degree and Teaching Certificate from 
David Lipscomb College. He holds a Master of 
Public Health degree from the University of 
Tennessee. 

His responsiblities with the TMA will include 
the development of communications and public 
service programs, field service activities, phy- 


sician placement service administration, and 
various committee assignments. 

University of Tennessee Medical Units 

MEMPHIS — The University of Tennessee 
College of Medicine is creating a new division 
of health care sciences which will coordinate 
the training of family physicians with an ex- 
panding university role in community medicine. 

UT Dean T. Albert Farmer (M.D.) an- 
nounced that the new division will supersede 
the Department of Preventive and Community 
Medicine. The new unit will be directed by 
Dr. John W. Runyan, Jr., professor of medicine 
and former head of the college’s endocrinology 
section. 

The Division of Health Care Sciences will 
include two departments, one concentrating on 
family practice and the other on community 
medicine. Dr. Runyan will chair the community 
medicine program, in addition to serving as 
overall director of both areas. A department 
chairman for family medicine is yet to be ap- 
pointed. 

The Department of Community Medicine 
will focus on means of delivering comprehensive 
primary care directed overall at disease pre- 
vention and health education. The Department 
of Family Practice will emphasize the family 
practice approach to health care delivery. 


pcf/OACil neui/ 


DR. CRAWFORD W. ADAMS, Nashville, was elected 
Governor for the American College of Cardiology at 
the American College of Cardiology meeting in San 
Francisco, California on Saturday, February 17, 1973. 
DR. ALBERT BIGGS, Knoxville, is director of the 
first clinical education center which has been estab- 
lished to improve the distribution of young doctors in 
the state. The Center is now in operation at the 
University Hospital. 

DR. MAURY W. BRONSTEIN, Memphis, has been 
elected President of the Memphis Academy of Internal 
Medicine. 

DR. DON CRIPPS, Smithville, has been appointed 
DeKalb County Physician and Medical Examiner. 

DR. JOHN M. DOBSON, Memphis, has been selected 
to head the Radiology staff for the new Methodist 
South John R. Flippin Memorial Hospital. 

DR. HAMEL E. EASON, Memphis, has been elected 
president of the Methodist Hospital medical staff suc- 
ceeding DR. E. N. STEVENSON. DR. EDWARD H. 
MABRY was named president-elect. 

DR. LLOYD ELAM, Nashville, has been appointed 


MARCH, 1973 


275 




to the Tennessee Health Planning Council by Governor 
Dunn for 1973. 

DR. HERBERT GIDDENS, Huntingdon, has been 
elected Chief of Staff of Carroll County Hospital. 
DR. OLIVER H. GRAVES, Jackson, has been elected 
Chief of Staff of the Jackson-Madison County General 
Hospital succeeding DR. ROY A. DOUGLASS. 

DR. RALPH S. HAMILTON, Memphis, has been 
elected President-Elect of the Ophthalmological Section 
of the Southern Medical Association for 1973. 

DR. JULIAN C. LENTZ, JR., Maryville, has been 
reappointed to the Council on Rural Health of the 
American Medical Association. 

DR. GRANT W. LIDDLE, Nashville, was guest 
speaker at the 22nd Annual Cardiac Symposium for 
Physicians held recently at Erlanger Hospital in Chat- 
tanooga. 

DR. WILLIAM MARSH, Chattanooga, has been 
named “Doctor of the Year” of the Chattanooga and 
Hamilton County Medical Society. 

DR. NORMAN A. McKINNON, Maryville, has been 
elected President of the Blount County Medical So- 
ciety. 

DR. H. A. MORGAN, JR., Lewisburg, has accepted 
the position of Health Officer of Dyer County effective 
January 15, 1973. He succeeds DR. W. G. SHELTON 
of Dyersburg who recently retired. 

DR. B. F. OVERHOLT, Knoxville, has been named 
“Young Man of the Year” by the Jaycees. 

DR. GORDON PEERMAN and DR. GEORGE HOL- 
COMB, Nashville, represented the Nashville Academy 
of Medicine at the February AMA National Leader- 
ship Conference in Chicago. 

DR. ROBERT M. RUCH, Memphis, has been elected 
President of the Memphis Obstetrical and Gynecologi- 
cal Society. 

DR. JOHN WILLIAM RUNYAN, JR., Memphis, has 
been named Director of the Division of Health Care 
Sciences at the U.T. Medical Units. The division will 
concentrate on the training of family physicians. 

DR. CHARLES GORDON SELL, DR. SARAH SELL, 
and DR. THOMAS F. FRIST, all of Nashville, re- 
cently conducted a forum on the heart in Franklin. 
DR. DAVID J. SLAGLE, Elizabethton, has been re- 
elected President of the Carter County Unit of the 
American Cancer Society. 

DR. JACK SMITH, Jamestown, has been appointed 
to the Governor’s Alcohol and Drug Dependency 
Advisory Commission. Also serving on the Commis- 
sion is DR. JACK M. MOBLEY of Knoxville. 

DR. LYNN WARNER, Dyersburg, served as the 
sponsoring physician for an Emergency Medical 
Technicians training course recently conducted in 
Dyersburg. 

DR. ROBERT WILSON, Kingston, has resigned as 
Roane County Medical Officer. 

DR. NAT T. WINSTON, JR., Nashville, will serve 
as the 1973 Crusade Chairman for the American 
Cancer Society. 

DR. M. M. YOUNG, Chattanooga, has been ap- 
276 


pointed to a one-year term on the State Health 
Planning Council. 

DR. GINO F. ZANOLLI, Oak Ridge, has been named 
Medical Director of the Oak Ridge Y-12 Plant. 


onnounccfflcnl/ 


CALENDAR OF MEETINGS 



STATE 

April 11-14 

Tennessee Medical Association, An- 
nual Meeting, Sheraton-Peabody Ho- 
tel, Memphis 

May 17 

Middle Tennessee Medical Associa- 
tion, Blue Grass Country Club, Hen- 
dersonville. 

MATOl'^AL 

March 29-30 

AMA National Conference on Rural 
Health, 26th, Statler-Hilton, Dallas 

April 1-4 

American College of Surgeons, Spring 
Meeting, Hilton and Americana Ho- 
tels, New York. 

April 2-7 

American College of Radiology, St. 
Francis Hotel, San Francisco 

April 3-5 

American Academy of Facial Plastic 
and Reconstructive Surgery, Chase 
Park Plaza Hotel, St. Louis 

April 6-8 

American Society of Internal Med- 
icine, Palmer House, Chicago 

April 9-12 

American Academy of Pediatrics, 
Spring Session, Sheraton-Boston Ho- 
tel, Boston 

April 9-13 

American College of Physicians, Con- 
rad Hilton, Chicago 

April 13 

7th National Congress on Socio- 
economics of Health Care, Marriott 
Motor Hotel, Chicago 

April 16-18 

American Association for Thoracic 
Surgery, Fairmont Hotel, Dallas 

April 16-19 

American Association of Neurological 
Surgeons, Century Plaza Hotel, Los 
Angeles 

April 23-28 

American Academy of Neurology, 
Sheraton-Boston Hotel, Boston 

April 25-27 

American Surgical Association, Cen- 
tury-Plaza Hotel, Los Angeles 

May 2-5 

American Gynecological Society, 
Broadmoor Hotel, Colorado Springs 

May 11-12 

American Association of Clinical 
Urologists, New York Hilton Hotel, 
New York 

May 13-17 

American Urological Association, 
New York Hilton Hotel, New York 

May 16-20 

A.merican Pediatric Society, Hilton 
Hotel, San Francisco 

May 21-24 

American College of Obstetricians 
and Gynecologists, Americana Hotel, 
Bal Harbour, Fla. 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 




May 21-24 

American Thoracic Society, Staffer 
Hilton Hotel, New York 

June 10-14 

American Proctologic Society, Detroit 
Hilton Hotel, Detroit 

June 14-16 

American Electroencephalographic 
Society, Statler Hilton, Boston 

June 16 

American College of Preventive Med- 
icine, New York 


June 20-22 

Endocrine Society, Sheraton-Chicago 
Hotel, Chicago 

June 23-24 

American Diabetes Association, Drake 
Hotel, Chicago 

June 24-27 

American Association of Plastic 
Surgeons, Waldorf-Astoria. New 
York 

June 24-28 

American Medical Association, 
Americana Hotel, New York 




COAtfAllifl^ 





University of Tennessee CME Courses 

The following continuing education courses are 
being offered by the University of Tennessee College 
of Medicine during 1973: 


Date: 

Course: 

March 26-31 

General Review Course for the Pamily 
Physician 

April 2-3 

A Clinical Approach to Common Skin 
Problems 

April 12-13 

Conference on the Exceptional Child 

May 9-11 

Pulmonary Disease 

May 9-12 

Clinical Electrocardiography (Paris 
Landing State Park Inn, Buchanan, 
Tennessee) 

May 14-18 

Intensive Review of the Science of 
Anesthesiology 

May 20-23 

Basic Principles of Rhinoplasty 


Vanderbilt University CME Courses 


Date 

March 23-24 
April 4-6 

April 27-28 

May 23-24 

July 11-12 
Sept. 19-21 


Title, Location, Program Coordinator 

2nd Annual Dragstedt Surgery Sym- 
posium, Underwood Auditorium, Van- 
derbilt, John Foster, M.D. 

Critical Care, (co-sponsor, American 
College of Physicians), Underwood 
Auditorium, Vanderbilt, Ms. Norma 
Shephard 

Pros and Cons of Group Practice, 
(Organization Alternatives in Medical 
Practice), University Club of Nash- 
ville, Paul Slaton, M.D. 

13th Annual Seminar in Psychiatry, 
Location to be announced, Vergil 
Metts, M.D. 

Ky. Med. Assn., Annual Meeting 
Lake Barkley, Kentucky 
Endocrinology (American College of 
Physicians) 

Underwood Auditorium, Vanderbilt, 
Grant W. Liddle, M.D. 


Sept. 26-28 


Oct. 10-12 


Oct. 25-27 


The Injured Child (American Academy 
of Orthopedic Surgeons) 

Underwood Auditorium, Vanderbilt, 
John Connolly, M.D. 

Hypertension (American College of 
Cardiology) 

Underwood Auditorium, Vanderbilt, 
Lawrence Grossman, M.D. 

Child Neurology 

Underwood Auditorium, Vanderbilt, 
Gerald Fenichel, M.D. 


University of Kentucky College of Medicine 

Date Title, Location, Program Chairman 

April 19-21 Pulmonary Thromboembolism, U.K. 

Medical Center, Kazi Mobinuddin, 
M.D. 


April 30- 
May 1 
May 2-4 


May 24-25 


Cardiac Diagnosis and Treatment, U.K. 
Medical Center, Borys Surawicz, M.D. 
Symposium on Pediatric Radiology, 
University of Kentucky, Frank R. 
Lemon, M.D. 

Annual Pediatric Review, U.K. Medical 
Center, Nancy Holland, M.D. 


1973 POSTGRADUATE COURSES 


These courses are arranged through the cooperation 
of the directors and the institutions involved. Registra- 
tions forms and requests for information are to be 
directed to: Registrar, Postgraduate Courses, Ameri- 

can College of Physicians, 4200 Pine Street, Phila- 
delphia, Pa. 19104. Tuition Fees: ACP Members and 
Fellows, $80; Nonmembers, $125; Associates, $40; 
Other Residents and Research Fellows, $80. 

Date Title and Location 


Mar. 22-24 CLINICAL RECOGNITION AND 
MANAGEMENT OE HEART DIS- 
EASE — 1973, University of Arizona 
Medical Center, Tucson, Ariz. 

Mar. 26-30 CARDIOLOGY — 1973 — TOPICS OP 
CURRENT INTEREST, Mount Sinai 
School of Medicine, New York, N.Y. 


MARCH, 1973 


277 


Apr. 4-6 

Apr. 24-27 
Apr. 25-27 
Apr. 25-27 

May 16-18 

May 16-18 
May 21-25 

May 21-25 

May 29- 
June 1 

June 4-8 
June 13-15 

June 18-22 

June 25-29 


RECENT ADVANCES IN DIAGNOSIS 
AND MANAGEMENT OE PULMO- 
NARY DISEASE, Virginia Mason Med- 
ical Center, Seattle, Wash. 
PULMONARY DISEASE, University of 
Pennsylvania School of Medicine, Phila- 
delphia, Pa. 

HEPATOBILIARY DISEASE IN CLIN- 
ICAL PRACTICE, University of Cali- 
fornia, San Erancisco, Calif. 
ADVANCES IN DIAGNOSIS AND 
MANAGEMENT OF INFECTIOUS 
DISEASE, University of Wisconsin, 
Madison, Wis. 

THE RHEUMATIC DISEASES— 
CLINICAL AND IMMUNOLOGICAL 
ASPECTS, University of Texas South- 
western Medical School, Dallas, Tex. 
CLINICAL AUSCULTATION OF THE 
HEART, Georgetown University Hospi- 
tal, Washington, D.C. 

INTERNAL MEDICINE: CURRENT 
CONCEPTS OF CLINICAL PROB- 
LEMS, University of Cincinnati Medical 
Center, Cincinnati, Ohio. 

INTENSIVE CARE UNITS, St. Vin- 
cent’s Hospital and Medical Center of 
New York, New York, N.Y. 

RECENT ADVANCES IN ENDO- 
CRINOLOGY AND THEIR CLINICAL 
APPLICATIONS, Royal Victoria Hospi- 
tal, Montreal, Que., Can. 
HEMATOLOGY, University of Wash- 
ington School of Medicine, Seattle, Wash. 
ONCOLOGY AND CHEMOTHER-. 
APY, University of Southern California, 
Los Angeles, Calif. 

CLINICAL ASPECTS OF BLOOD 
TRANSFUSION, Michigan State Univ., 
East Lansing, Mich. 

ADVANCES IN INTERNAL MEDI- 
CINE: RECENT PERSPECTIVES, 

1973, Banff, Alta., Can. 


Family Planning Seminars 

special two-day, tuition-free seminars in family 
planning for family practice physicians and interested 
specialists have been scheduled in Atlanta and Jack- 
sonville, Florida. They will focus on various aspects 
of family planning: the chemical and mechanical 

means of contraception; reproductive anatomy, 
physiology and biochemistry; the role of allied health 
personnel in family planning; and demography, human 


sexuality and the socio-psychological aspects of family 
planning. 

Sponsored by Emory University and The American 
College of Obstetricians and Gynecologists on the 
dates listed below, physicians may write or phone: 

Jules M. Terry, M.D. 

Emory University 
Dept, of Ob./Gyn. 

100 Edgewood Ave. Rm. 805 
Atlanta, Georgia 30303 
(404) 659-1212 x 4213 


Dates: 

(Atlanta) 


March 7-9 
March 29-30 
April 12-13 
April 26-27 


May 10-11 
May 16-18 
May 24-25 
June 28-29 


(Jacksonville ) 
March 26-27 
April 26-27 
May 28-29 
June 25-26 


To help defray expenses, a per diem will be paid 
to physicians accepted for the courses. 


Symposium on Pediatric Radiology 

This three-day symposium to be held May 2-4, 1973 
will deal with many practical problems in the diag- 
nosis of abdominal, chest, and skeletal disease in 
childhood. A distinguished guest and University of 
Kentucky faculty will join in presenting the confer- 
ence, organized to meet the need of practicing pedia- 
tricians and radiologists. 

Direct inquiries to: Frank R. Lemon, M.D., Con- 
tinuing Education, College of Medicine, University of 
Kentucky, Lexington, Kentucky 40506. 

Graduate Program On Mental 
Retardation Open to Physicians 

Interested Tennessee physicians are urged to apply 
for a unique 21 -month, full-time, graduate educational 
program offered at the University of Michigan in the 
fields of mental retardation and related disabilities. 

The program is one of only two in the U.S. but “not 
too many physicians apply and we’d like a lot more,” 
says Arthur W. Fleming, M.D., director. The pro- 
gram is sponsored by the Maternal and Child Health 
Service of the Health Services and Mental Health 
Administration of HEW. 

The program ordinarily begins in the fall. Require- 
ments for admission are the completion of an approved 
residency in pediatrics or psychiatry, and an interest 
and promise of working with handicapped children. 

Further information may be obtained from Doctor 
Fleming, Department of Maternal and Child Health, 
The School of Public Health, The University of Michi- 
gan, 109 S. Observatory St., Ann Arbor, Mich. 48104. 





Dollars Today — 
Doctors Tomorrow 

American Medical Association 
Education and Research Foundation 

535 North Dearborn Street, Chicago 10, Illinois 



278 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


K I IMESED® provides more complete relief. 

Gastroenteritis, colitis, gastritis or duodenitis can produce 
spasm or hypermotility, gas distention and discomfort. But Kinesed 
can provide a balanced formulation to relieve these symptoms; 

□ belladonna alkaloids— for the hyperactive bowel 

□ simethicone— for accompanying distention and pain due to gas 

□ phenobarbital— for associated anxiety and tension 


Contraindications; Hypersensitivity to barbiturates or bel- 
ladonna alkaloids, glaucoma, advanced renal or hepatic 
disease. 

Precautions:' Administer with caution to patients with in- 
cipient glaucoma, bladder neck obstruction or urinary 
bladder atony. Prolonged use of barbiturates may be habit- 
forming. 

Side effects; Blurred vision, dry mouth, dysuria, and other 


atropine-like side effects may occur at high doses, but are 
only rarely noted at recommended dosages. 

Dosage: Adults: One or two tablets tlrree or four times daily. 
Dosage c;m be adjusted depending on diagnosis and severity 
of symptoms. 

Children 2 to 12 years: One-half or one tablet three 
or foiu- times dmly. Tablets may be chewed or swallow^ed 
with liquids. 



STUART PHARMACEUTICALS 1 Division of ICI America Inc. I Wilmington, Del. 19899 


(from the Greek kinetikos, 
to move, 

and the Latin sedatus, 
to calm) 

KINESED® 

antispasmodic/sedative/antiflatulent 

Eachchewable tablet conhum: 16 mg. phenobarbital (warn- 
ing: may be habit-forming); 0.1 mg. hyoscyamine sulfate; 

0.02 mg. atropine sulfate; 0.007 mg. scopolamine hydro- 
bromide; 40 mg. simethicone. 


liuckwalla (Saurormlus obcsus): 

:iis southwestern desert liziird seeks 
lelter in crevices of rocks, 
hen attempts are made to prolre him 
Dm Iris niche, he gulps air 
itil liis abdomen is distended up to 
<ty per cent over its normal size... 
us wedging Ihmself tightly 
•place-and pixiixaitingxiipture. 



‘REPORT ON THE 1972 OPINION 
SURVEY OF THE AM A MEMRERSHIP - 
TENNESSEE RESPONDENTS” 

CENTER FOR HEALTH SERVICES RESEARCH AND DEVELOPMENT AMERCIAN MEDICAL ASSOCIATION 

QUESTION 1 

Which one of the following comes closest to the policy position you would like the AMA 
to maintain as your representative on the national scene in Washington? 

RESPONSES 



Tennessee 

Total U.S. 

Seek to retain as many as possible of the basic principles of private 
practice (freedom of choice, fee-for-service, voluntarism, etc.) in 
any governmental health program that would be adopted 

12.2% 

13.\% 

Resist any form of a government health plan except that limited 
to medical and related care for the poor 

20.9% 

16.4%) 

I have not decided, or do not wish to state a position at this time 

2.7% 

3.3% 

Other Responses 

4.3%. 

7.2% 


QUESTION II 


There are numerous proposals before Congress for national health insurance. ASSUMING that 
one or a combination of these might be enacted into law, which of the following concepts would 
you prefer? 


a. A plan in which the federal government, under contracts with 

physicians and institutional and other providers would administer 
and pay for most of the nation’s medical care 

b. A plan in which federal funds would be used to pay for care of 

the poor; and, in which employers would be required to purchase 
qualified health insurance policies and plan for their employees 
and their families and pay most of the premium 

c. A plan in which the individual purchases a qualified health insurance 

policy or plan for himself and his family, and the federal govern- 
ment contributes full payment of premium for the poor, and for 
other income groups a partial payment related to the family’s taxable 
income (with the federal contribution decreasing as the taxable 
income increases) 

d. A plan in which the federal government would provide financial 
assistance to cover only the catastrophic costs of illnesses 

e. None of the above 

f. I have not decided, or do not wish to state a position at this time . . 

Other Responses 


2.1% 4.8% 


7.2% 9.2% 


56.7% 55.7% 

16.9% 14.1% 

6.2% 5.3% 

4.5% 4.3% 

6.4% 6.6% 


QUESTION III 

Of the following non-institutional non-governmental arrangements, which would you prefer: 
a. Eee-for-service {without prepaid capitation)? 74.3% 66.6% 

* Respondents from Tennessee numbered 1,676 in Tennessee and 1.8 per cent of the total 94,035 compris- 
ing 53.4 per cent of the physicians mailed to respondents nationwide. 


286 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


b. Contract practice (prepaid capitation system) in which you are 

reimbursed on a fee-for-service basis? 

c. Contract practice (prepaid capitation system) in whieh you are 

reimbursed according to a negotiated formula (e.g., base salary 
plus percentage)? 

d. Contract practice (prepaid capitation system) in which you are 

reimbursed on a salary basis? 

Other Responses 


RESPONSES 


Tennessee 

Total U.S. 

17.0% 

21.0% 

3.8% 

6.2% 

1.8% 

3.0% 

2.5% 

3.8% 


QUESTION IV 


If a compulsory nationalized health service were adopted by Congress in the near future, which of 
the following courses of action would you choose? (Please check the one choice which most 
nearly describes what you think you would do.) 


a. Join the federal program and continue to practice in it 

b. Seek an administrative post in the federal program 

c. Continue to practice in my specialty under the federal program, 

but would switch to a university, hospital, industrial setting, or 
clinic center 

d. Continue my private practice with those patients who would pay 

my private fees, whether or not the patient pays an additional 
mandatory federal premium 

e. Leave the practice of medicine 

f. I have not decided, or do not wish to state a position at this time . 

Other Responses 


23.0% 

24.6% 

0.8% 

1.6% 

9.7% 

11.7% 


32.0% 

28.1% 

6.9% 

7.6% 

23.7% 

21.6%, 

3.8% 

4.7% 


QUESTION V 

Do you think the current situation regarding professional liability (malpractice insurance and liti- 
gation) causes you to order: RESPONSES 



Yes 

No 

Undecided 

Other 

Responses 

extra lab tests, x-rays and other 
diagnostic procedures? 

Tennessee 

69.5% 

24.5% 

2.4% 

3.7% 

Total U.S. 

10.7% 

23.1% 

2.3% 

3.9% 

extra consultations? 
Tennessee 

56.9% 

33.7%) 

2.7% 

6.7% 

Total U.S. 

59.3% 

31.2% 

2.9% 

6.6% 

extra hospitalization? 
Tennessee 

47.3% 

40.8% 

3.8% 

8.2% 

Total U.S. 

44.5%, 

42.8%c 

4.4% 

8.5% 


QUESTION VI 

In your opinion is there a serious shortage in YOUR immediate location of practice of: 

RESPONSES 



Yes 

No 

Do Not 
Know 

Other 

Responses 

a. physicians? 
Tennessee 

21.5% 

61.4% 

2.8% 

2.3% 

Total U.S. 

25.3% 

69.0% 

2.9% 

2.8% 


MARCH, 1973 


287 


RESPONSES 




Yes 

No 

Do Not 
Know 

Other 

Responses 

b. specialists in YOUR specialty? 

Tennessee 


20.3% 

70.9% 

1.9% 

6.8% 

Total U.S. 


17.1% 

72.8% 

2.3% 

7.9% 

c. residency positions teaching 
hospitals in YOUR specialty? 

Tennessee 


18.7% 

59.1% 

10.9% 

11.3% 

Total U.S. 

In your opinion does AMA put 

14.9% 

QUESTION VII 
proper emphasis on: 

Too 

60.8% 12.0% 

RESPONSES 

Not No 

12.4% 

Other 


Yes 

Much 

Enough 

Opinion 

Responses 

a. Scientific Activities? 

Tennessee 

67.3% 

4.9% 

13.0% 

10.6% 

4.2% 

Total U.S. 

66.3% 

5.8% 

13.3% 

10.1% 

4.5% 

b. Socioeconomic Issues? 

Tennessee 

44.7% 

8.9% 

27.1% 

14.7% 

4.5% 

Total U.S. 

39.3% 

7.9% 

35.1% 

12.3% , 

5.5% 

c. Medical Education? 

Tennessee 

69.3% 

1.8% 

16.3% 

8.9% 

3.6% 

Total U.S. 

67.9% 

4.2% 

16.4% 

7.8% 

3.7% 

d. Continuing Education? 

Tennessee 

64.1% 

2.4% 

22.8% 

7.8% 

2.9% 

Total U.S. 

e. Practice Management Problems 

63.3% 

0 

4.5% 

21.9% 

6.6% 

3.7% 

Tennessee 

36.6% 

3.9% 

36.2% 

19.0% 

4.3% 

Total U.S. 

32.9% 

4.6% 

39.8% 

17.7% 

5.0% 

f. Legislative Issues? 

Tennessee 

49.0% 

10.0% 

27.9% 

9.7% 

3.3% 

Total U.S. 

44.5% 

9.9% 

31.6% 

9.9% 

4.2% 

g. Membership Benefits? 

Tennessee 

56.3% 

6.7% 

22.0% 

11.7% 

3.3% 

Total U.S. 

51.8% 

7.0% 

31.6% 

10.7% 

4.3% 

h. Communication to the Public? 

Tennessee 

27.1% 

3.2% 

59.2% 

7.6% 

2.9% 

Total U.S. 

24.1% 

3.3% 

62.5% 

6.6% 

3.4% 

i. Communication to the 
Medical Profession? 

Tennessee 

57.5% 

1.7% 

31.0% 

6.6% 

3.3% 

Total U.S. 

55.2% 

2.4% 

32.4% 

6.2% 

3.9% 


288 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


QUESTION VII (Continued) 

Total Respondents 

A majority of responding AMA members indicated that AMA was placing “proper” emphasis 


on five areas 

• scientific activities (66.3%) 

• medical education (67.9%) 

• continuing education (63.3%) 

• membership benefits (51.8%) 

• communication to the 

medical profession (55.2%) 


Communication to the public received the lowest percentage of “yes” responses (24.1%). 

The issues which received the greatest percentage of “not enough” emphasis responses were: 

• communication to the public (62.5%) 

• practice management problems (39.8%) 

• socioeconomic issues (35.15%) 

By comparison, the issues which received the greatest percentages of “proper” emphasis re- 
sponses from total AMA membership registered the following percentages of “proper” em- 
phasis responses in Tennessee 


• 

scientific activities 

(67.3%) 

• 

medical education 

(69.3%) 

• 

continuing education 

(64.1%) 

• 

membership benefits 

(56.3%) 

• 

communication to the 



medical profession 

(57.5%) 


The issues which received the lowest percentage of “not enough” emphasis responses from 
total AMA membership registered the following percentages of “not enough” emphasis responses 
among Tennessee respondents. 

• communication to the public (59.2%) 

• practice management problems (36.2%) 

• socioeconomic issues (27.1%) 


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MARCH, 1973 


289 


Because you 
practice 

medicine in the 
\blunteer State 



JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



I carry one of the heaviest 
lent loads in the country, 
ce this may include 
imber of patients with 
tritis and duodenitis... 
i should know 
re about Librax® 


ps reduce 

iety-reiated G.I. symptoms 

tient may blame his attacks of gastritis or 
enitis on “something he ate” but contribut- 
.ctors may be his job, 

;al problems, financial 
les or some other unmen- 
d source of stress and 
,sive anxiety that 
^rbated the condition. 

;her it is “something 

or “something eating him,” adjunctive 
iX can help. Librax offers both the antianxiety 
1 of Librium® (chlordiazepoxide HCl), that can 
•elieve excessive anxiety, and the dependable 
holinergic action of Quarzan® (clidinium Br), 
an help reduce gastrointestinal hypermotility 
lypersecretion. 


; prescribing, please consult complete product information, 
tnary of which follows: 

vindications: Patients with glaucoma; prostatic hyper- 
/ and benign bladder neck obstruction; known hypersen- 
i to chlordiazepoxide hydrochloride and/or clidinium 
de. 

ngs: Caution patients about possible combined effects 
Icohol and other CNS depressants. As with all CNS- 
drugs, caution patients against hazardous occupations 
ing complete mental alertness {e.g., operating machinery, 
g). Though physical and psychological dependence have 
been reported on recommended doses, use caution in 
istering Librium (chlordiazepoxide hydrochloride) to 

I addiction-prone individuals or those who might increase 
withdrawal symptoms (including convulsions), following 

tinuation of the drug and similar to those seen with bar- 
tes, have been reported. Use of any drug in pregnancy, 
on, or in women of childbearing age requires that its 
ial benefits be weighed against its possible hazards. As 

II anticholinergic drugs, an inhibiting effect on lactation 
ccur. 

Jtions: In elderly and debilitated, limit dosage to smallest 
ve amount to preclude development of ataxia, overseda- 
■ confusion (not more than two capsules per day initially; 
se gradually as needed and tolerated). Though generally 
:ommended, if combination therapy w ith other psycho- 
5 seems indicated, carefully consider individual pharma- 
c effects, particularly in use of potentiating drugs such as 
inhibitors and phenothiazines. Observe usual precautions 
sence of impaired renal or hepatic function. Paradoxical 
)ns (e.g., excitement, stimulation and acute rage) have 
eported in psychiatric patients. Employ usual precautions 


Patient-oriented dosage — up to 
8 capsules daily in divided doses 

For optimal response, dosage can be adjusted to suit 
patient needs— 1 or 2 capsules, 3 or 4 times a day. 

To help relieve 
anxiety-linked 
symptoms in gastritis 
and duodenips 
X •'f adjunctive 

Librax*^ 

Each capsule contains 5 mg chlordiazepoxide HCl 
and 2.5 mg clidinium Br. 


in treatment of anxiety states with evidence of impending 
depression; suicidal tendencies may be present and protective 
measures necessary. Variable effects on blood coagulation have 
been reported very rarely in patients receiving the drug and oral 
anticoagulants; causal relationship has not been established 
clinically. 

Adverse Reactions: No side effects or manifestations not seen 
with either compound alone have been reported with Librax. 
When chlordiazepoxide hydrochloride is used alone, drowsiness, 
ataxia and confusion may occur, especially in the elderly and 
debilitated. These are reversible in most instances by proper 
dosage adjustment, but are also occasionally observed at the 
lower dosage ranges. In a few instances syncope has been 
reported. Also encountered are isolated instances of skin 
eruptions, edema, minor menstrual irregularities, nausea and 
constipation, extrapyramidal symptoms, increased and 
decreased libido— all infrequent and generally controlled with 
dosage reduction; changes in EEG patterns (low'-voltage fast 
activity) may appear during and after treatment; blood 
dyscrasias (including agranulocytosis), jaundice and hepatic 
dysfunction have been reported occasionally with chlordiaz- 
epoxide hydrochloride, making periodic blood counts and liver 
function tests advisable during protracted therapy. Adverse 
effects reported with Librax are typical of anticholinergic agents, 
i.e., dryness of mouth, blurring of vision, urinary hesitancy and 
constipation. Constipation has occurred most often when 
Librax therapy is combined with other spasmolytics and/or 
low residue diets. 


Roche Laboratories 

Division of Hoffmann-La Roche Inc. 

Nutley, New Jersey 07110 




ANSWERS TO THE COOPER QUIZ 
from pages 236-237 

JAMA, Sept. 4, 1972 

1. False. “The following conclusions have been 

reached: (1) There are no data to support the 

contention that halothane should be given no more 
often than every three months. (2) Halothane is 
a safely and easily administered anesthetic agent. 

(3) Haltohane does cause liver damage in the 
rare individual, particularly following repeated 
exposures. The mechanism for this is unknown. 

(4) A careful follow-up is mandatory for every 
patient receiving halothane. Evidence of liver 
toxicity contraindicates its further use in that pa- 
tient. (5) Patients receiving repeated anesthesia 
are drawn from different population than those 
receiving only one. Particular emphasis should 
be placed on nutrition and intercurrent drug 
therapy in the repeatedly exposed group. (6) If 
a patient seen preoperatively has received halothane 
recently and sufficient time has elapsed to allow 
symptoms of an untoward reaction to appear, a 
careful search by history and by physical and 
laboratory examination should be directed toward 
detection of such a reaction. If this investigation 
yields negative results, the choice of anesthesia 
should be governed by the requirements of the 
operation and the experience of the anesthetist. 
(7) All anesthetic alternatives to halothane have 
dangers associated with their use. (8) The distinc- 
tion between ‘major’ and ‘minor’ anesthesias is 
unjustified and should not govern the selection of 
anesthetic agent. (9) The informed anesthesiologist 
is best prepared to make the choice of anesthesia.” 
(p. 1142) 

2. True. “Strontium 87m scanning was performed 
on 30 children with suspected infection involving 
the musculoskeletal system. All 20 patients, who in 
final analysis were considered to have septic ar- 
thritis, osteomyelitis, or diskitis, had positive scans. 

Sept. 11,1972 

3. True. “Echocardiography is a useful, safe, non- 
invasive procedure for evaluating cardiac function 
and anatomy. Diamond et al demonstrated that 
echocardiographic findings were specific in right 
ventricular overload secondary to atrial septal de- 
fects or tricuspid regurgitation. Abnormal inter- 
ventricular septal movement was observed in all 
instances in which a left-to-right shunt existed.” 
(p. 1243) 

4. True. “When it is present, abnormal septal mo- 
tion is suggestive of right ventricular volume over- 
load. However, it is not present in all patients 
with an increased RVD index or an elevated 
pulmonary-to-systemic flow ratio (or both). Al- 
though echocardiography seems to be a good 
screening test, it is not specific enough to dif- 
ferentiate among the defects that produce right 
ventricular volume overload nor to differentiate 
a patient with an abnormal volume from one with 
a normal volume.” (p. 1245) 


5. Ealse. “Unlike bronchial cancer, which has as- 
sumed almost epidemic proportions in many coun- 
tries, cancer of the trachea is rare, and cancer of 
the larynx is uncommon. Laryngeal cancer, never- 
theless, resembles bronchial cancer in being es- 
sentially a disease of men who smoke.” (p. 1253) 

6. True. ‘There are definite indications for a sur- 
gical approach to the solitary thyriod nodule. 
These include the nonfunctioning nodule in men 
and women younger than 40 years of age, a thy- 
roid nodule in a child with a history of irradi- 
ation of the neck, any solitary nodule in a man 
over 40 years old, nonfunctioning solitary nodules 
in women over 40 years old, and situations in 
which calcification seen on x-ray films is sug- 
gestive of thyroid cancer.” (p. 1265) 

7. False. “Catheter-associated urinary tract infec- 
tion (UTIc) is a significant infection hazard de- 
spite available methods of prevention. Many UTIc 
pathogens are transmitted between catheterized 
patients by passive carriage on the hands of at- 
tendants. A recent study of Serratia marcescens 
UTIc demonstrated that the risk of urinary tract 
colonization varied directly with the extent of 
clustering of such patients. Their geographic dis- 
persal, especially separation of those infected from 
those noninfected, warrants trial as an adjunctive 
measure for prevention of UTIc.” (p. 1270 — 
Abstract) 

Sept. 18, 1972 

8. True. “A number of agents may affect vitamin 
B ^2 or folate metabolism. Among these agents 
are the oral contraceptive drugs which appear to 
cause malabsorption of polyglutamic folate and 
may induce megaloblastic anemia in some women. 
The infrequency of megaloblastic anemia secondary 
to the use of these agents appears obvious from 
the fact that millions of women used them for al- 
most a decade before this untoward effect was 
recognized.” (p. 1371) 

9. False. ‘The data presented herein demonstrate 
a significant reduction of serum B^., levels in 
women taking oral contraceptives. This reduction 
can occur within five months and serum levels 
may fall to values indistinguishable from other 
forms of vitamin B ^^2 deficiency. In spite of the 
drastic reduction in serum levels found in some 
women, no anemia or evidence of tissue depletion 
was detected. Also no detectable change in serum 
B^ 2 ‘t’inding proteins occurred. This study also 
confirms the work of others in demonstrating a 
reduction in serum folate in women taking oral 
contraceptives. In addition, the simultaneous re- 
duction of both serum B ^2 and folate levels was 
demonstrated in some of these women. Oral ad- 
ministration of folic acid had no effect on serum 
B ^2 values in three of these subjects, suggesting 
that the serum vitamin B ^2 decrease was not sec- 
ondary to folate deficiency.” (p. 1374) 

10. False. “The protein content of ascitic fluid was 
determined in 26 patients with intra-abdominal 
neoplasms or inflammation in whom patency of 
the portal venous system was evaluated directly 


292 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


at laparotomy or autopsy. Ascitic fluid was high 
in protein content (respectively 54% and 62% of 
the plasma level) in both groups except when 
portal system occulsion was superimposed on the 
underlying disturbance, in which case ascitic fluid 
was low in protein content (respectively 8% and 
24% of the plasma level). Viewed in the light 
of observations on the protein content of ascitic 
fluid in patients with hepatic cirrhosis, these data 
suggest that, in the absence of marked hypo- 
proteinemia, peritoneal fluid of low protein con- 
tent signifies marked impairment to portal blood 
flow into the liver.” (p. 1380) 

11. Good. “All sources of fuel are needed to supply 
the increasing power needs of a growing popula- 
tion. Atomic fuel competes economically with 
fossil fuels under most conditions and eliminates 
undesirable environmental pollution by stack ef- 
fluents. Both fossil- and atoniic-fueled plants have 
waste hot water which necessitates controls to 
prevent changes in the ecology. The 25-year 
record of health and safety of atomic energy pro- 
grams in the United States should be comforting 
to the public. Radiation exposures from com- 
mercial power reactors have been a very small 
fraction of permissible limits, and the Atomic 
Energy Commission has recently further restricted 
releases from such reactors so that the average 
exposure to the public will be only about 1% of 
that from the natural background.” (p. 1392) 

12. True. “James Wilson has dog preparations for 
comparative steroid effectiveness in preventing 
shock lung. Food and Drug Administration-rated 
equivalent doses of corticosteroids were given. 
The dogs in which he used pharmacologic doses 
of dexamethasone developed cardiac arrhythmias. 
Ninety percent of them died within a few minutes 
after the administration of the drug, and the re- 
mainder died before the conclusion of the experi- 
ment. This was in contradistinction to his dogs 
which received methylprednisolone sodium suc- 
cinate, 30 mg/kg of body weight, and survived 
remarkably well. 

“Whether these arrhythmias were the result of 
the drug itself or the preservatives cannot be 
said.” (p. 1403) 

EDITOR’S NOTE: The evidence here quoted is 
experimental but the paper describes cardiac ar- 
rhythmias in a human after dexamethasone ad- 
ministration. 

Sepf. 25, 1972 

13. True. “Malignancies must be diagnosed before 
they can be cured. Our study suggests that during 
the last half-century there has been some improve- 
ment in the diagnosis of cancer in American mu- 
nicipal hospitals, but this improvement has been 
limited. In 1922, Wells found clinically un- 
suspected cancer in 32.6% of all patients with 
cancer at autopsy, whereas 50 years later we 
found this error in 26.2% of similar patients 
representing a 6% improvement in clinical cancer 
diagnoses. However, our study has shown that 
an added 13.9% of all cancer patients had in- 
completely diagnosed cancer which almost al- 


ways (97%) was fatal. We cannot be sure how 
many of these patients with incompletely diag- 
nosed malignancy would have been included by 
Wells in this ‘not diagnosed’ group. Our review 
of clinical charts suggests few patients with ‘sus- 
pected-unconfirmed cancer’ had sufficient ante- 
mortem evidence to support clinical diagnoses 
of cancer. If these patients are considered to- 
gether with the undiagnosed group there are 906 
patients or 33.2% with ‘not diagnosed’ cancer, 
a figure very similar to those of both Wells and 
Willis.” (p. 1474) 

Tiie New England Journal of Medicine Sept. 7, 1972 

14. True. “The measurement of serum thyroxine is 
an indicator of the total hormone present in the 
serum in both bound and free forms. It is di- 
rectly dependent on the protein bound portion 
which constitutes the bulk of the total serum 
thyroxine in normal individuals. 

“Physiological factors such as pregnancy or 
estrogen use, altering the thyroxine binding 
globulin (TBG), are reflected in the value for 
the serum thyroxine. The resulting score can be 
misleading, thus imposing a serious diagnostic 
problem in many patients.” (p. 1483) 

15. False. “In the general population the incidence 
of PDA at sea level is about 0.04 per cent, but 
rises to 0.72 per cent at high altitude. In a four- 
year period in our hospital the incidence of PDA 
in premature infants weighing 1750 g or less at 
birth has been 15.3 per cent. The incidence with- 
in the group did not rise with increasing pre- 
maturity. Although the precise explanation is 
not known, several factors may account for this 
high incidence of PDA in premature infants.” 
(p. 476) 

16. False. ‘'Our results suggest that early operative 
intervention may be essential for survival. All six 
infants required assisted ventilation for IRDS; the 
onset of the signs of PDA was associated with 
progression of the pulmonary disease and severe 
heart failure developed in all. The only survivor 
was an infant in whom operative closure of the 
ductus arteriosus was done at the age of eight 
days, when pulmonary function had just begun 
to worsen. Because the condition of these infants 
deteriorated rapidly, we recommend early cather- 
ization and operative closure of the PDA as soon 
as the pulmonary status begins to worsen — before 
irreparable lung damage occurs from severe pul- 
monary edema superimposed on severe IRDS.” (p. 
477) 

EDITOR’S NOTE: IRDS = Idiopathic Respira- 
tory Distress Syndrome 

17. False. “The cause of the hypoalbuminemia pres- 
ent at the outset of treatment may be due to a 
multiplicity of factors. Increased catabolism may 
result from definite albuminuria. Decreased syn- 
thesis may be due to protein deprivation, the 
uremic state, and hyperosmolarity. Decreased 
albumin concentration may also be a dilutional 
effect in patients with excessive extracellular-fluid 
volumes. 


MARCH, 1973 


293 


“Conversely, the improvement in albumin con- 
centration and in total exchangeable albumin 
demonstrated in this study must result from in- 
creased protein intake, from an improvement in 
the toxic state created by uremia, and from a 
decrease in serum osmolarity. The effective oncotic 
pressure has been shown in isolated liver perfusion 
studies and in vivo to affect the rate of synthesis 
of albumin. Repeated dialysis results in a striking 
decrease in the proteinuria as urine volume di- 
minishes. Careful management of water intake will 
prevent the dilutional effect of overhydration. 
Whatever the cause of the hypoalbuminemia, fre- 
quent dialysis after a relatively normal protein 
intake is critical in its correction. 

“The ultimate aim of unattended home dialysis 
— rehabilitation of the chronically uremic patient 
as a functioning member of society — is only possi- 
ble if a reasonable degree of health and strength 
is attained. That this is possible is attested by the 
return to full activity of the majority of the 46 
patients in this program, (p. 480) 

EDITOR’S NOTE; The patients in this study were 
fed 80 grams of protein a day and had dialysis 
three times a week. (Total of 24 to 30 hours.) 

Sept. 14, 1972 

18. True. “Table 1. Summary of Drugs Useful in 
Treatment of Parasitic Infections, (p. 496) 


INFECTION 

Helminths: 

Tapeworms: 

T saginata, 

T solium, 

D latum, 

H nana 
Roundworms: 

E vermicularis 

A lumbncoides 

Strongyloides 

Trichuris 

Trichinella 

Hookworms 


Creeping eruption 
Trematodes: 

5 japonic um 
S mansoni & 

S hematohium 

Clonorchis 

Protozoa: 

Malaria 

Amebiasis 


Giardiasis 


DRUG 


Niclosamide; quinacrine 


Pyrantel; pyrvinium; pi- 
perazine; thiabendazole. 

Pyrantel; piperazine; 
thiabendazole. 

Thiabendazole; 

pyrvinium. 

Hexylresorcinol enemas. 

Thiabendazole; steroids. 

Tetrachlorethylene; 
bephenium; pyrantel, 
thiabendazole. 

Thiabendazole 

Tartar emetic 

Hycanthone; niridazole, 
antimony dimercap- 
tosuccinate; stibophen. 

None 

Chloroquine-primaquine; 
quinine; pyrimetha- 
mine; sulfonamides. 

Tetracycline; emetine; 
metronidazole; 
chloroquine; 
di-iodohydroxyquin . 

Quinacrine; metroni- 
dazole.” 


19. False. “The syndrome of iodide-induced hyper- 
thyroidism (Jodbasedow) is not common and has 
been reported to occur in patients with iodine- 
deficient goiter after iodide replenishment. As 
part of a larger study to assess the effects of 
iodide administration on thyroid hormone synthesis 
in normal subjects and in patients with various 
underlying disorders of the thyroid, iodides (5 
drops of a saturated solution of potassium iodide) 
were administered in eight patients with nontoxic 
goiter residing in Boston, an area of iodine suf- 
ficiency. Hyperthyroidism developed during and 
after iodide administration in four of the eight — 
an unexpectedly high frequency. This finding sug- 
gests that the homeostatic mechanism controlling 
thyroid hormone synthesis and release in these 
patients is not functioning normally. We recom- 
mend that large doses of iodides not be adminis- 
tered to patients with nontoxic goiter.” (p. 523 — 
Abstract ) 

20. True. “Ouabain significantly improved the im- 
paired LV function of patients with AMI. These 
patients did not have ischemic cardiac pain at the 
time of the study, and only four of the 16 patients 
were in clinical ‘LV failure.’ Before ‘routine’ use 
of digitalis can be recommended in such patients, 
we need to know the effects of digitalis on ventric- 
ular size and on myocardial oxygen consumption 
and whether there are long-term clinical or hemo- 
dynamic benefits of such therapy.” 

21. False. “Bacterial concentrations exceeding a cer- 
tain number of colonies per milliliter of urine are 
not proof of the renal origin of the bacteriuria. 
Systemic factors, such as overhydration, dehydra- 

. tion, or reduced concentration ability, as well as 
local factors, such as bladder volume and emptying 
frequency, may alter bacterial concentrations in 
either way so that spuriously low or falsely high 
concentrations may ensue. 

“If an infection is localized in the lower urinary 
tract, dilution by freshly secreted urine can only 
reduce the count concentration, provided the rate 
of urine flow is high, the bladder emptying time 
short and the residual volume minimal. If any one 
of these factors is not present the dilution effect 
may either not appear or be grossly blunted. 

“Conditions within the kidney are somewhat 
different, and resemble continuous cultivation sys- 
tems in which fresh medium (urine) is constantly 
supplied and the culture drained off at the same 
time. Below a certain perfusion flow more bacteria 
will be produced than will be carried away, and 
thus their concentration in the drainage fluid will 
rise to a ‘climax’ level; above a certain flow more 
bacteria will be carried away than will be pro- 
duced, so that their concentration will tend pro- 
gressively to lessen to ‘sterility.’ Sudden accelera- 
tion of the perfusion flow in a slowly draining 
infected parenchyma will lead to a washing out of 
bacteria from well perfused areas, as well as per- 
fusion of previously underperfused loci, inside or 
even outside the renal parenchyma. As a result, 


294 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


an initial elevation of bacterial concentration in 
the drainage fluid and a subsequent drop-off will 
be observed, provided no obstruction of outflow is 
present." (p. 533) 

22. False. "Reversible nonobstructive hydronephrosis 

and hydroureter can be produced by urinary-tract 
infections. Reversible hydronephroses and hydrou- 
reters. without urinary-tract infection but accom- 
panied by peritonitis, are rare. In the three cases 
reported below, hydronephroses and hydroueters 
were apparently concomitant symptoms of general- 
ized peritonitis. The hydronephroses were of the 
nonobstructive type and disappeared spontaneously 
within four to 20 months after onset.” (p. 535) 
EDITOR’S NOTE: Permit us to quote the last 

paragraph of this paper. 

"It should be emphasized that the association 
of peritonitis and hydronephrosis and hydroureter, 
if overlooked, may confuse the clinical picture 
and result in unnecessary diagnostic procedures.” 

Sept. 28, 1972 

23. False. "Among 24 patients with gonadal dys- 
genesis who had been treated for five or more 

years with stilbestrol, endometrial carcinoma de- 
veloped in two and possibly in a third. Three 

cases of endometrial carcinoma in patients with 

gonadal dysgenesis have previously been reported 
by others. Three of the five definite carcinomas 
were of an unusual mixed, or adenosquamous, type. 
The cancers were detected at an average age of 
31 years. The only reported case of endometrial 
carcinoma in an untreated patient with primary 
amenorrhea occurred at the age of 79 years. The 
early age at occurrence of this unusual type of 
tumor suggests a carcinogenic role of exogenous 
estrogens in these patients.” (p. 628, Abstract) 

24. True. “Headache. Robinson found no relation 
between hypertension and headache; Badran et al. 
observed none except among persons with diastolic 
pressures greater than 130 mm of mercury, in 
whom there was a greater prevalence of head- 
ache. This finding in persons of very high diastolic 
pressure would probably account for the clinical 
teaching that headache is a symptom of hyperten- 
sion. Unfortunately, in the present study too few 
patients had such high diastolic pressures for 
meaningful analysis. 

“Epistaxis. The findings presented are at odds 
with those of Mitchell, who measured the blood 
pressure of patients whose primary symptom was 
epistaxis. Of patients without apparent nasal ab- 
normality to account for the bleeding, 75 per cent 
had a diastolic blood pressure higher than 95 mm 
of mercury in comparison with only 6 per cent 
of a control group of patients with nasal disease. 
The difference persisted after age adjustment. The 
current study found no association of epistaxis 
with high blood pressure, and despite differences 
in methodology and study population, the conclu- 
sions of the two studies are not readily reconciled. 
However, even if epistaxis is associated with hyper- 
tension, it is a relatively infrequent symptom, for 



MARCH, 1973 


295 



even under the broad definition used here (any 
nosebleeds at any time) only 7 to 14 per cent of 
persons reported it. 

‘‘"Other symptoms. Robinson found no associa- 
tion between dizziness and hypertension; in the 
present study dizziness was more common only in 
persons with very high diastolic blood pressure 
(higher than 110 mm of mercury). The prevalence 
of tinnitus did not vary with blood pressure.” (p. 
633) 

25. False. “The present study was prompted by the 
occurrence of bacteriologic relapse in several 
patients with H. influenzae meningitis treated with 
ampicillin in accordance with the most stringent 
recommendations. 

“One of the most striking differences between 
the treated groups was the presence of fever, which 
was more prolonged and of greater magnitude in 
ampicillin-treated patients. These findings are 
similar to those of Schulkind and his associates, 
who noted prolonged fever in 21 ampicillin-treated 
patients as compared with 16 recipients of chloram- 
phenicol. Previous reports had indicated no sig- 
nificant differences in the febrile response of 
patients with H. influenzae meningitis to ampicil- 
lin and chloramphenicol treatment. 

“Six recipients of ampicillin suffered bacteri- 
ologic relapse. Although this was a retrospective 
chart review and there are conditions that may 
have changed over the years, one cannot over- 
look the fact that no relapse occurred with 
chloramphenicol therapy. 

“Relapse of H. influenzae meningitis after 
chloramphenicol treatment has been reported. In 
all but three cases, failure occurred in patients 
who received a portion of their treatment intra- 
muscularly, a route now known to be unreliable 
and one no longer sanctioned.” (p. 636) 

26. True. “Our data demonstrate that statistically 
significant individual variation in serum urate levels 
may occur in healthy people during the course of a 
year. Furthermore, transient hyperuricemia may 
be more common than has heretofore been sus- 
pected, especially if serial samples are examined. 
This phenomenon of transient hyperuricemia ap- 
pears to be unrelated to any readily determined 
pathologic condition. In agreement with larger 
series, we found no significant differences between 
white and black men in serum urate levels. 

“Rubin and his co-workers, studying the inter- 
relations between repeated determinations of serum 
urate, cholesterol and cortisol levels, noted a 
considerable variability in urate values in the 
same subject. Furthermore, in the Framingham 
study, a higher percentage of the male population 
showed at least one elevation if four biennial 
determinations were considered than if only a 
single determination was considered. The unex- 
pected finding of an apparent seasonal influence 
deserves further evaluation. Banerjee and Saha 
observed no seasonal influence, and we have 
found no other studies of the effects of sunlight 
or seasons on serum uric acid levels. Interestingly 


enough, we have induced significant urate eleva- 
tions with artificial sunlight in two normal volun- 
teers. 

“This study demonstrates that serum urate values 
are very labile, and that day-to-day transient 
elevations and seasonal variations are important 
factors to consider whenever one attempts to 
evaluate the importance of age, sex, stress, drugs, 
heredity, or socio-economic effects, etc., upon 
serum urate levels.” (p. 650) 

The Archives of Internal Medicine Sept. 1972 

27. True. “Although combining anemias associated 
with infection, malignancy, and rheumatoid 
arthritis may mask pertinent differences, evidence 
strongly sugg.,sis smidar, n not identical, mecha- 
nisms in the pathogenesis of the anemia. Abnormal- 
ities in iron metabolism are well described in this 
type of anemia. This study corroborates the find- 
ing of low serum iron level and low TIBC in 
these patients. There was no correlation between 
marrow iron stores and serum iron levels or rela- 
tive percentage saturation of transferrin, when the 
TIBC was below 280^g/100 ml. Bone marrow 
biopsy showed iron in the marrow of 31 to 40 
chronically ill patients. In 21 of these cases iron 
stores were distinctly increased, a finding con- 
sidered to be characteristic of the syndrome.” 
(p. 325) 

28. False. “Therefore, we suggest that a relative im- 
pairment in protein synthesis is the determining 
factor in the low levels of albumin, transferrin, and 
eryihropoietin seen in the anemia of chronic dis- 
orders. The additional observation that albumin 
and transferrin are reduced in proportion to the 
severity of the anemia (and presumably, there- 
fore, to the severity of the underlying disease) 
suggests that this impairment extends to all the 
proteins involved in hematopoiesis, including those 
concerned with erythropoietic stimulation, iron 
transport, and protoplasmic synthesis. The similar- 
ity of this anemia to the anemia of protein defi- 
ciency further supports this unifying concept. The 
inability to increase the synthetic rate of a wide 
variety of proteins reflects the severity of the dis- 
ease and disappears upon correction of the under- 
lying disease process.” (p. 326) 

29. False. “Changes in levels of serum cholesterol 
and triglycerides with physical training are not of 
great magnitude. Siegel et al found small but sig- 
nificant decreases in mean serum cholesterol values 
after conditioning and a variable decrease in serum 
triglycerides. Mann and associates also found de- 
creases in cholesterol level, but noted an increase 
in triglycerides after training which was attributed 
to an increased dietary intake. In this study there 
was no appreciable change in values for serum 
cholesterol or triglycerides.” (p. 345) 

30. True. “Left ventricular function has been studied 
in patients with acute myocardial infarction by 
relating cardiac output to left ventricular filling 
pressure and measuring the alterations that occur 
following volume expansion. Such studies have 


296 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


demonstrated that the left ventricle in acute in- 
farction does operate on a ventricular function 
curve and that maximum cardiac output is ob- 
tained when the filling pressure of the left ventricle 
is between 20 and 24 mm Hg. Elevation of the 
left ventricular filling pressure beyond 25 mm 
with dextran infusion often does not produce 
further increase in cardiac output and on occa- 
sions may lower it. Even in patients with conges- 
tive heart failure and cardiogenic shock complica- 
ting the acute infarction, the left ventricular filling 
pressure may vary over an extremely wide range. 
Therefore, in patients with depressed ventricular 
function accompanying myocardial infarction, such 
as those presented in this study, left ventricular 
filling pressure was regulated around 18 to 22 mm 
Hg. In patients whose initial filling pressures are 
above 25 mm Hg, reduction of filling pressure 
would be indicated by phlebotomy or diuretic 
therapy to the optimum range. On the other hand, 
patients whose filling pressures to 18 to 22 mm 
Hg by dextran infusion.” (p. 375) 

The Annals of Internal Medicine Sept. 1972 

31. False. “The 150 patients were divided into three 

groups according to date of implant: those im- 

planted between 1961 and 1964 and followed for 
70 to 108 months (group A); those implanted in 
1965 and 1966 and followed for 45 to 69 months 
(group B); and those implanted in 1967 and 1968 
and followed for 24 to 44 months (group C). 

“These data show an improved survival among 
the paced patients compared with unpaced patients 
but a decreased survival compared with a matched 
sample from the general population. Survival rates 
were higher in patients in whom pacemakers were 
implanted after 1964 than in patients with earlier 
implants. The overall survival rates for our study 
group were comparable with those reported by 
Morris and associates and Torresani and col- 
leagues. 

“Sudden death occurred in 6 of the 34 deaths 
in group A, in 2 of 18 deaths in group B, and in 
1 of the 9 deaths in group C. The total of 9 
sudden deaths is substantially higher than the 4.2 
sudden deaths expected (E < 0.05) from a 

matched general population sample from the 
Tecumseh study. Postmortem examinations were 
made in 5 of the 9 sudden-death patients (4 in 
group A, 1 in group B), and there was no evidence 
of acute myocardial ischemia. None of the nine 
patients exhibited clinical symptoms immediately 
before death, which suggested a major or minor 
myocardial ischemia episode.” (p. 346) 

32. True. “Of the 20 patients who were paced for 
refractory congestive heart failure, 16 were initially 
improved. After 2 years, 17 of the 20 patients 
had survived, and 13 continued to show marked 
improvement. 

“Twenty-six patients had congestive heart failure 
for the first time after pacing was started, com- 
pared with an expected 6.3 cases (E < 0.001). 
Time of occurrence after the initial implant varied, 
(Continued on page 299) 



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298 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



(Continued from page 297 ) 

with 10 cases occurring during the first 6 months 
of pacing and 11 additional cases, after from 7 
to 24 months of pacing. The other five patients 
developed congestive heart failure from 30 to 54 
months after the implant. 

“Thirteen of the 26 patients had a disease pre- 
disposing to development of congestive heart 
failure. Five patients were diabetic, four were 
hypertensive, two had experienced an acute myo- 
cardial infarction, one carried a concurrent diag- 
nosis of Paget’s disease, and one patient was 
thyrotoxic at first presentation. The prevalence 
rates of rates of diabetes mellitus and coronary 
artery disease in this subgroup were similar to 
those reported in the Framingham study, but 
hypertension was less prevalent in the paced group. 
Analysis of other clinical data did not disclose 
any associated diseases, signs, or symptoms by 
which congestive heart failure after pacing could 
have been predicted. 

“With medical management 4 of the 26 patients 
became asymptomatic, 9 were improved but had 
residual synij^toms, 6 shewed no clinical change, 
and 7 developed more severe congestive heart 
failure.” (p. 347) 

33. True. “Permanent ventricular pacing of patients 
has produced excellent long-term survival rates. 
Physicians may optimistically assure pacing candi- 
dates that acceptance of a pacemaker does not 
involve risks of mortality and morbidity appreci- 
ably greater than found in the normal population. 
Patients permanently paced for refractory conges- 
tive heart failure complicating atrioventricular 
block respond excellently to pacing and are not 
subject to higher risk of mortality than other 
paced patients. Paced patients may develop con- 
gestive heart failure for the first time after pacing; 
many will respond to standard pharmacologic 
therapy and can therefore be adequately treated 
by the alert primary physician. The incidence 
of myocardial infarction and cerebrovascular acci- 
dent in paced patients appears to be no greater 
than in the general population.” (p. 350) 

34. False. “Our results suggest that in patients with 
diabetic neuropathy the capacity for marked digi- 
tal vasoconstriction is generally maintained, even 
when evidence indicates autonomic insufficiency 
elsewhere. These wide fluctuations in cutaneous 
blood flow depend primarily on the vasoconstrict- 
ing influence of the adrenergic sympathetic nerves. 
Therefore, prompt vasoconstriction to almost zero 
blood flow in response to cold strongly suggests 
that peripheral sympathetic fibers are intact. Al- 
though increased vessel sensitivity to circulating 
catecholamines accoun.s for considerable vasocon- 
striction in sympathectomized patients, it is not 
likely to cause such complete vasospasm in re- 
sponse to cold. One could argue that local factors 
related to diabetic microangiopathy might cause 
vasoconstriction, but ischemia is a stimulus to 
vasodilation rather than vasoconstriction. This is 


illustrated by reactive hyperemia following cold- 
induced vasoconstriction and successful arterial 
surgery for an ischemic limb. 

“Only 1 of 19 subjects appeared to be totally 
autosympathectomized in the present study.” (p. 
354) 

35. False. “Thrombocytopenia occurred on two sep- 
arate occasions in a patient while she was receiving 
sodium cephalothin. After recovery, a test dose of 
cephalothin (1 g) produced a 50% drop in the 
platelet count.” (p. 401) 

36. True. “Although triiodothyronine (Tg) was first 
discovered in 1952 by Gross and Pitt-Rivers, its 
physiological importance was not clarified until 
development of sensitive methods for measuring 
this iodoaminoacid. We now know that Tg plays 
a major role in producing the hyperthyroid state. 
In 1968 we first described a syndrome of hyper- 
thyroidism caused by Tg elevation only, which we 
have termed Tg toxicosis. Recently we have also 
noted that Tg levels may be elevated for some 
time before the development of the usual form of 
thyrotoxicosis, thus serving as a premonitory mani- 
festation of the hyperthyroid state. 

“Over the past year we have studied 10 patients 
from our endocrine clinic who, after treatment 
of the usual form of thyrotoxicosis and a period 
of euthyroidism, developed recurrent hyperthyroid- 
ism with Tg as the only elevated iodoaminoacid.” 
(p. 410) 


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Precautions: Ideally, supportive therapy is indicated for anemic, 
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Adverse Reactions: Most frequently encountered are anorexia, 
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jOUMIQl 

OF THE 

TENNESSEE MEDICAL 
ASSOCIATION 

APRIL, 1973 

Vol. 66 No. 4 

Published Monthly By 
Tennessee Medical Association 
Office of Publication, 
112 Louise Avenue 
Nashville, Tenn. 37203 

Second Class Postage Paid at 
Nashville, Tenn. 

TMA OFFICERS 

President 

Wm. T. Satterfield, Sr., M.D. 

1188 Minna Place 
Memphis 38104 
President-Elect 
O. Morse Kochtitzky, M.D. 
2104 West End Ave. 
Nashville 37203 
Chairman, Board of Trustees 
C. Gordon Peerman, Jr., M.D. 
21st & Hayes Medical Bldg. 

Nashville 37203 

EDITORIAL STAFF 

Editor 

John B. Thomison, M.D. 
Managing Editor and 
Business Manager 
Jack E. Ballentine 

TMA EXECUTIVE STAFF 

Executive Director 

Jack E. Ballentine 
Assistant Executive Director 
L. Hadley Williams 
Executive Assistant 
John M. Westenberger 
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William V. Wallace 
Executive Assistant 
for Legislation 
John R. Coles 

The Journal of the Tennessee 
Medical Association 
112 Louise Ave. 
Nashville, Tennessee 37203 

Published monthly under the direction of 
the Board of Trustees for and by members 
of The Tennessee Medical Association, a 
nonprofit organization, with a definite 
membership for scientific and educational 

purposes. 

Subscription $9.00 per year to non- 
members; single copy, 75 cents. Payment 
of Tennessee Medical Association 
membership dues includes the subscription 
price of this Journal. 
Devoted to the interests of the medical 
profession of Tennessee. This association 
does not officially endorse opinions 
presented in different papers published 
herein. Copyright, 1973 by the Journal of 
the Tennessee Medical Association. 
Advertisers must conform to policies and 
regulations established by the Board of 
Trustees of the 
Tennessee Medical Association. 


conleni/ 

SCIENTIFIC SECTION 

329 Diagnostic Applications of Ultrasound in Obstetrics: A Review, 

G. William Bates, M.D. 

333 The Role of the County Medical Society, Norman A. McKinnon, M.D. 

334 Red Cell (Packed Cell) Transfusions: An Appeal to Reason, John 1 

V. Petrucci, M.D. | 

336 A Brief Look at Methadone Maintenance, David H. Knott, M.D., ? 
P.H.D. and Robert D. Fink, M.D. 

338 Staff Conference 

342 Self-Evaluation Quiz 

344 Topics in Nuclear Medicine 

346 From the Tennessee Department of Public Health 
349 EKG of the Month 
351 Laboratory Medicine 

NEWS AND ORGANIZATIONAL SECTION 

361 President’s Page 

362 The New President 
364 Editorial 

367 In Memoriam 
367 New Members 

367 Programs and News of Medical Societies 

369 National News 

372 Medical News in Tennessee 

372 Personal News 

373 Announcements 
382 Special Item 
385 The Viewing Box 

403 Placement Service 

404 Index to Advertisers 

Contents listed in CURRENT CONTENTS/CLINICAL PRACTICE 
of The Institute for Scientific Information 


INSTRUCTIONS TO CONTRIBUTORS 

Manuscripts submitted for consideration for publication in the JOURNAL 
OF THE TENNESSEE MEDICAL ASSOCIATION should be addressed to 
the Editor, John B. Thomison, M.D., P.O. Box 70, Nashville, Tennessee 
37202. 

Manuscripts must be typewritten on one side of letterweight paper. 
Either double or triple spacing and wide margins must be provided to 
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be numbered and clipped or stapled together, but they should not be 
placed in a binder. 

Bibliographic references should not exceed twenty in number docu- 
menting key publications. They should appear at the end of the paper. 
The bibliographic references must conform to the style used in the 
American Medical Association publications, as, — Alais, FG: What is Known 
About it, J. Tennessee M. A., 35:132, 1950. 

Illustrations should be numbered and identified with the author’s name. 
The editor will determine the number, if any, of illustrations to be used 
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Engraving cost for illustrations in excess of $25 will be billed to the 
author. They will not be returned unless specifically requested. 

If reprints are wanted, the desired number should be indicated in the 
letter accompanying the manuscript. No reprints are provided free and 
a reprint cost schedule will be forwarded upon request. 


jOUMMlI 

OF THE TENNESSEE MEDICAL ASSOCIATION 

OWNED AND PUBLISHED BY THE ASSOCIATION 

APRIL, 1973 
VOLUME 66, NO. 4 


Diagnostic Applications of 
Ultrasound in Obstetrics: A Review 


In the past five years there has been a wide- 
spread interest in the application of ultrasonics 
to the specialty of obstetrics and gynecology. 
Through the pioneering efforts of Donald in 
Scotland, Heilman, Kobayashi, Taylor, Gottes- 
feld, and others in the United States, the diag- 
nostic usefulness of ultrasonics in this speciality 
has been established. While older techniques 
are being refined, new applications are being 
discovered so the ultimate usefulness of the 
modality remains unknown. Ultrasonic studies 
have largely been confined to the academic in- 
stitutions due to lack of equipment and trained 
personnel, but gradually, it is finding its way into 
smaller clinical settings. 

Until recently the obstetrician has had only 
limited access to the fetus and intrauterine 
milieu, relying primarily on his clinical judgment 
in predicting the outcome of pregnancy. New 
advances in biochemistry, immunology, nuclear 
medicine, and sonography now permit the ob- 
stetrician to directly and indirectly survey the 
intrauterine milieu, and better select the fetus 
and mother at risk so that appropriate therapy 
can be rendered. The purpose of this paper is to 
outline the clinical situations that can be diag- 
nostically aided by sonography. 

Before any drug or diagnostic technique can 
be utilized in the pregnant woman, its safety 
must be established to prevent deleterious ef- 
fects in the mother, the unborn fetus, and the 
progeny of the fetus. It must not cause terato- 

From the Department of Obstetrics and Gynecology, 
University of Tennessee Memorial Research Center 
and Hospital, Knoxville, Tenn. 

Presented at The Ultrasonic Medical Diagnostic 
Symposium. The University of Tennessee, Knoxville, 
Tenn.. December 5-6, 1972. 


G. WILLIAM BATES, M.D. 

genic effects or chromosomal aberrations. A 
number of investigations have been performed in 
establishing the safety of ultrasound in the gravid 
woman, and several are worthy of mention. 

The early reports of Macintosh^® in studies 
isonating human lymphocytes demonstrated an 
increased number of chromosomal aberrations 
in isonated cells. His work stimulated other in- 
vestigations, particularly in Great Britain. 
Donald and Heilman^ in a combined study 
analyzed for fetal anomalies the outcome of 
1114 apparently normal pregnancies isonated at 
various stages of gestation. Both continuous and 
pulsed ultrasound were given at a frequency of 
2MHz, not exceeding 10 mW/cm.- The overall 
incidence of fetal anomalies was 2.7%, and no 
increased incidence of anomalies occurred in 
fetuses exposed during the period of organo- 
genesis. These results were compared with 
63,238 nonisonated deliveries, which had an 
anomaly rate of 4.8%. 

Watts^'^ compared the number of chrom- 
osomal aberrations of isonated human lympho- 
cytes in tissue culture with control samples and 
found no increased incidence of chromosomal 
damage. This work was substantiated by 
Abdulla^ by exposing cultured lymphocytes to 
both diagnostic and therapeutic intensities 
through stepwise increase. He noted red cell 
aggregation at high intensities, but no increase 
in chromosomal abnormalities. 

Lucas, studying chromosomes in newborn 
infants receiving continuous ultrasound for 
monitoring fetal heart rate during labor, found 
no difference in the chromosomes of 24 isonated 
infants and 12 controls. McClain^"^ in a tera- 
tologic study exposed pregnant rats during the 


APRIL, 1973 


329 


period of organogenesis from day 8 thru day 13 
of gestation to diagnostic levels of ultrasound 
for periods ranging from Ve to 2 hours. Post- 
mortem examination following delivery showed 
no soft tissue or skeletal abnormalities in the 
treated groups. Thus, despite scattered reports 
casting doubt on the safety of ultrasound, its 
safety for use during pregnancy appears to be 
well established. 

CLINICAL APPLICATION 

The earliest applications of sonography to the 
obstetrical patient were in the areas of detection 
and monitoring of the fetal heart during preg- 
nancy and labor and in measurement of the 
biparietal diameter of the fetal skull using the 
A-mode scan. Utilizing continuous ultrasound 
and the Doppler principal, the fetal heart beat 
can be perceived as early as 12 weeks, whereas 
with the conventional fetoscope the earliest de- 
tection of the pulsating fetal heart is at 17 to 18 
weeks gestation. Continuous sonography is now 
being incorporated into fetal monitoring units, 
replacing the phonocardiogram for external 
fetal monitoring during labor. 

FETAL MATURITY 

For years the obstetrician has been seeking 
methods to aid in the determination of fetal 
maturity in order to appropriately time delivery 
in high risk infants to avoid the problem of, 
prematurity. Reliance on menstrual history and 
estimation of fetal size by palpation are notori- 
ously unreliable. X-ray studies of fetal bone 
maturation have proven helpful, but expose the 
fetus to ionizing radiation and have inherent 
diagnostic limitations. Biochemical studies of 
the amniotic fluid including measurement of 
creatinine, lecithin and osmololality give accu- 
rate prediction of fetal maturation, but again 
expose the mother and fetus to a slight risk in 
obtaining the amniotic fluid specimen. 

The early studies of Donald® demonstrated the 
usefulness of sonography in outlining and mea- 
suring the fetal head. Calibration of the A-scope 
provided an accurate means of measuring the 
fetal biparietal diameter and subsequent studies 
with the compound B-scope have provided fetal 
head measurements within the accuracy of ± 
2 mm. Weingold®° evaluated fetal head size in 
75 patients undergoing repeat Cesarean section, 
utilizing both the A- and B-mode scope in longi- 
tudinal and cross sectional scans. Serial measure- 

330 


ments were obtained at 14 day intervals begin- 
ning at the 32nd week of gestation. His serial 
measurements showed a linear growth rate of 
the fetal head with average measurements of 
7.8 cm at 32 weeks, 8.0 cm at 34 weeks, 8.6 
cm at 36 weeks, 8.7 cm at 38 weeks, and 9.1 
cm at 40 weeks. The previous work of Taylor^® 
had shown that 9 1 percent of infants with a BPD 
of greater than 8.5 cm would weigh in excess of 
2500 grams, and 97 percent with a BPD of 9.0 
would weigh more than 2500 grams. On the 
basis of this work, Weingold established criteria 
for his study that infants with a biparietal diam- 
eter less than 8.4 cm would be premature, 8.5 
to 8.6 borderline, and greater than 8.7 cm 
mature. Of the 75 patients, 12 went into sponta- 
neous labor, necessitating obligatory C-section. 
Four of these had measurements of less than 8.4 
cm and were premature, five were in the border- 
line zone for maturity with measurements of 8.5 
to 8.7, and the other three were mature. The 
remaining 63 patients who were carried to a 
sonographic measurement of 8.7 cm, underwent 
elective repeat Cesarean section and all were 
mature, weighing in excess of 2500 grams. Fetal 
head measurements were obtained post delivery 
with calipers and correlated within ± 2mm of 
the sonographic measurement. Technical sources 
of error were found in patients with deep en- 
gagement of the vertex, occiput anterior and 
occiput posterior presentation, and in breech 
presentation with the vertex under the costal 
margin. Weingold compared his results with 
107 patients undergoing elective repeat C-section 
where the decision to operate was made on 
history, clinical findings, and x-ray, and noted 
an overall prematurity rate of 16 percent. 

Heilman and co-workers® have shown a linear 
growth pattern of the BPD in normal, diabetic, 
and hypertensive patients, independent of re- 
tarded or accelerated fetal somatic growth. 

Utilizing the fact that biparietal diameter in- 
creases in a linear fashion, Heilman, Kohorn, 
and others have derived formulae, based on the 
BPD, to predict the fetal weight. lanniruberto® 
applied these formulae to 100 normal preg- 
nancies isonated for BPD within 48 hours of 
labor. Fetal weight was estimated within a 
mean accuracy of 368 grams but such wide in- 
dividual variations occurred that the authors 
concluded that this method had little clinical 
usefulness. Previous data in correlating BPD 
with fetal maturity were confirmed. 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


PLACENTAL LOCALIZATION 

For years the obstetrician has sought ways to 
localize the placenta, especially in patients with 
suspected placenta previa. The growing use of 
amniocentesis has further increased this need. 
X-ray soft tissue placentography, though useful, 
is frequently unreliable, and isotopic placental 
scanning and placental arteriography carry 
maternal and fetal risks. The ultrasonogram is 
accurate and safe in placental localization, and 
is beginning to replace these other methods. In 
early studies, Gottesfeld^ reported a 97% ac- 
curacy rate in placental localization but could 
not localize the low lying posterior placenta. 
Donald^ corrected this weakness by decreasing 
the frequency from 2.5 MHz to 1.5 MHz and 
adjusting the gain. Kobayashi and Hellman^*^ 
evaluated 100 patients undergoing hysterotomy 
for C-section or therapeutic abortion and cor- 
related the sonographic location with the im- 
plantation site found at surgery. They were 
able to localize the placenta accurately in 95%. 
Scans were obtained utilizing the full bladder 
technique, and a 2 MHz transducer. They were 
able to adjust the gain without changing the 
frequency, and produce excellent scans. 

Kohorn^“ compared localization utilizing the 
B-scan and 99'" technitium scintillation scanning 
in 50 patients. The placenta was accurately 
localized in 46 patients using both techniques, 
but the ultrasonic method was superior in that 
it visualized the fetus and the relation of the 
fetus and placenta to the internal os of the 
uterus. Though he felt the ultrasonic method 
was the method of choice, the isotopic scan was 
recommended for use in smaller hospitals. 

DIAGNOSIS OF INTRAUTERINE 
FETAL DEATH 

When fetal death occurs, amniotic fluid pene- 
trates the epidermis and underlying tissues with 
subsequent epidermal separation, protein break- 
down, and the creation of new tissue — fluid 
interspaces. This results in changes in the 
acoustical impedance resulting in a “fluffing” of 
the fetal outline. Gottesfeld® screened 113 
patients with suspected fetal death on the basis 
of absent fetal heart tones, cessation of fetal 
movement, vaginal bleeding, and retarded 
uterine growth. Sixty patients were found by 
sonographic criteria to have fetal death in utero, 
forty-seven patients carried viable pregnancies 
to term, and six patients were lost to follow 


up. Within the first 12 hours of fetal death, 
“fluffing” appears, and though suggestive of fetal 
death, is not pathognomonic as it may be seen 
in pregnancies complicated by diabetes mellitus 
and Rh isoimmunization. Within forty-eight 
hours of death, there is a marked increase in 
“fluffing” with collapse of the fetal skull and 
thorax, and difficulty in demonstrating the fetal 
vertebral column. 

In early pregnancy, Donald^ and Heilman® 
have demonstrated the appearance of a tropho- 
blastic ring at four weeks. At eleven weeks a 
fetal echo can be demonstrated, and beyond 
twelve weeks the fetal head with a midline echo 
appear. Early fetal death or missed abortion can 
be suspected when these outlines fail to appear 
or the sonogram shows loss of definition, frag- 
mentation, or a break in the gestational sac. 
Twenty-five patients with suspected missed abor- 
tion were followed with serial sonograms and 15 
were proven by D & C to have a missed abor- 
tion. The remainder had normal growth pat- 
terns sonographically, and subsequently carried 
to term. 

DIAGNOSIS OF ECTOPIC PREGNANCY 

Ultrasonic diagnosis of the ectopic pregnancy 
has been less reliable than culdotomy and 
laparoscopy. Kobayashi^^ evaluated 21 cases of 
surgically proven ectopic pregnancy and estab- 
lished a correct diagnosis in 16 or 76.2%. 
Varma^® was able to correctly diagnose 18 
ectopic pregnancies in 20 surgically proven 
cases. Criteria for an ectopic gestation are: (1) 
diffuse amorphous uterine echoes, (2) uterine 
enlargement, and (3) absence of an intrauterine 
pregnancy. Extrauterine findings include an ir- 
regular poorly defined mass containing some 
echoes, and an ectopic gestational sac. 

DIAGNOSIS OF HYDATIDIFORM MOLE 

Molar tissue, which consists of small fluid- 
filled vesicles, lets ultrasound through easily. 
With low intensities, the uterus appears to be 
almost empty, but when the intensity is raised, 
multiple echoes fill the entire uterus, producing a 
scatter effect. Numerous investigators have es- 
tablished the usefulness of the B-scan in this 
entity. Donald reported observations of this 
entity in 1961. Nineteen moles were confirmed 
by Taylor,^’’ et al, in 78 suspected cases. The 
material included one false negative but no false 
positive findings. In the series described by 
Gottesfeld,'^ 17 hydatidiform moles were demon- 


APRIL, 1973 


331 


strated in 61 suspects examined by the B-method 
with no false positive results. Other reports 
have similar accuracy. In patients who have 
been treated for trophoblastic disease, a rise in 
the gonadotropin titer may indicate a pregnancy 
or a recurrence of the trophoblastic disease. A 
sonogram demonstrating the presence or absence 
of a gestational sac will aid in this difficult 
differential diagnosis. 

OTHER APPLICATIONS 

The safety and reliability of diagnostic ultra- 
sound in pregnancy have been well established. 
In pregnancies with concomitant ovarian or 
uterine lesions such as cysts and tumors, sonar 
may be useful in establishing the location and 
character of the lesion. In patients with indwell- 
ing intrauterine devices who are suspected of 
being pregnant, sonography will localize the 
lUD and demonstrate signs of pregnancy with- 
out exposing the patient to ionizing irradiation 
or intrauterine manipulation, and a diagnosis of 
multiple gestation can be established several 
weeks prior to the radiographic demonstration 
of skeletal calcification. 

CONCLUSION 

It must be kept in mind that diagnostic ultra- 
sound is not to be used in isolation but as a 
supplementary aid to other diagnostic proce- 
dures. As interest becomes widespread, equip- 
ment more refined, and more physicians become 
trained, the application of ultrasound to ob- 
stetrics and gynecology and other fields of med- 
icine will increase. The potential of this 
diagnostic method remains to be established. 

BIBLIOGRAPHY 

1 . Abdulla, U : Effect of ultrasound on chromosome 
of lymphocyte cultures. Br Med J, 3:797. 1972. 

2. Donald, I, et al: Safety of Diagnostic ultra- 
sound in obstetrics. Lancet, 1:1133, 1970. 

3. Donald, I: Ultrasonics and other electronic tech- 


niques. J Ohstet Gynecol of Br Conunonw, 69:1036, 
1962. 

4. Donald, 1: Sonar in obstetrics and gynecology. 

Yearbook of Obstetrics and Gynecology, 242, 1967. 

5. Gottesfeld, KR, et al: Ultrasonic placentography 
— A new method for placenta localization. Am J 
Obstet Gynec, 96:538, 1966. 

6. Gottesfeld, KR: The ultrasonic diagnosis of in- 
trauterine fetal death. Am J Obstet Gynec, 108:623, 
1970. 

7. Gottesfeld, KR, et al: Diagnosis of hydatidiform 
mole by ultrasound. Obstet and Gynecol, 30:163, 
1967. 

8. Heilman, LM, et al: Sources of error in sono- 
graphic fetal mensuration and estimation of growth. 
Ant J Obstet Gynec, 99:662, 1967. 

9. lanniruberto. A, and Gibbons, JM, Jr: Predicting 
fetal weight by ultrasonic B-scan cephalometry. An 
improved technic with disappointing results. Obstet 
Gynecol, 37:689, 1971. 

10. Kobayashi, M, et al: Placental localization by 
ultrasound. Am J Obstet Gynec, 106:279, 1970. 

11. Kobayashi, M, et al: Ultrasound. An aid in 

the diagnosis of ectopic pregnancy. Am J Obstet 
Gynec, 103:1131, 1969. 

12. Kohorn, El, et al: Placental localization. A 

comparison between ultrasonic compound B scanning 
and radioisotope scanning. Am J Obstet Gynec, 103: 
868, 1969. 

13. Lucas, M: Study of chromosomes in the new- 
born after ultrasonic fetal heart monitoring in labour. 
Br Med J, 3:795, 1972. 

14. McClain, RM: Teratologic study of rats exposed 
to ultrasound. Am J Obstet Gynec, 114:39, 1972. 

15. Macintosh, IJC: Chromosome aberrations in- 

duced by an ultrasonic fetal pulse detector. Br Med 
J, 4:92, 1970. 

16. Taylor, ES: Ultrasound diagnostic techniques 

in obstetrics and gynecology. Am J Obstet Gynec, 
90:655, 1961. 

17. Taylor, ES: Clinical use of ultrasound in 

obstetrics and gynecology. Am J Obstet Gynec, 99: 
671, 1967. 

18. Varma, TR: The value of ultrasonic B-scanning 
in diagnosis when bleeding is present in early preg- 
nancy. Am J Obstet Gynec, 114:607, 1972. 

19. Watts, P: Ultrasound and chromosome damage. 
Br J of Radiol 45:335, 1972. 

20. Weingold, AB, et al: Ultrasonic determination 
of fetal maturity at repeat cesarean section. Obstet 
Gynecol, 38:294, 1971. 


To live content vith small means; to seek elegance rather than luxury, and refinement rather than fashion; to 
be worthy, not respectable, and wealthy, not rich; to study hard, think quietly, talk gently, act frankly; to listen 
to stars and birds, to babes and sages with open heart; to bear all cheerfully , do all bravely, await occasions, 
hurry never. In a word, to let the spiritual, unhidden and unconscious, grow up through the common. This is 
to be my symphony. 

W. E. Channing, 1818-1901 


332 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


The Role of the 
County Medieal Soeiety 

NORMAN A. McKinnon, m.d. 


I believe that if we are to anticipate the 
continued independence of the private physician 
a sound effective county medical society is ab- 
solutely essential. The hospital staff will not 
fill this roll. May I emphasize that the hospital 
staff is a separate organization, although it is 
made up of most of the same people who are 
members of the county medical society. 

The hospital staff does not speak for the 
doctors. Medically and economically it is an 
organization that of necessity must be hospital 
oriented and must answer to a bureaucracy 
which is made up of non-medical people. It is 
your county medical society that will represent 
your views. I hope it will serve to take them 
to our state society and eventually to the na- 
tional organization, the A.M.A. 

I am sorry to say that not every practicing 
physician in the county is a member of this local 
society or the state or A.M.A. They all have 
their reasons for not joining. These assemblies 
may not always be to our liking, and we may 
disagree, but they are our organizations. The 
county medical society is the only one that truly 
speaks for the doctor, and from our local society, 
as representatives to the state and national 
associations. 

If these organizations do not always express 
our view points then let’s work through the 
county medical society to get our ideas across. 
I hasten to add that these are not only political 
organizations, but are scientific groups too. The 
splendid history of medical care in this country 
is in great part due to the influence of the 
county, state and national medical societies. Dr. 
William Sodeman has succinctly summarized this 
in the A.C.P. Bulletin and the AM A Medical 
News, Oct. 2, 1972. 

We stand at the threshold of a great many 

* Presidential Address, Blount County Medical So- 
ciety. 


changes in the delivery of medical care, with the 
dignity of the physician and his independence to 
take care of his patients as he sees best threat- 
ened by third party interference. This inde- 
pendence is what has made America really out- 
standing in the field of medicine. All of these 
things are gradually being taken away from us 
by the sophistry of politicians and the syllogistic 
reasoning of bureaucrats. If we do not stand 
strong together and face this challenge I am 
afraid that many of us will see the practice of 
medicine change greatly in our lifetime, and it 
may not be to our liking. 

Just let me give you one example of what 
your county medical society can do for you. If 
you recall a few months ago the Aetna Life In- 
surance Company challenged the physician’s 
right to be able to set a fee which was agreeable 
with the doctor and patient for services per- 
formed. This insurance company interjected 
itself between the doctor and patient and even 
threatened to go to court if the patient decided 
not to pay the physician’s bill. It was not the 
hospital staff that challenged this concept; it 
was the medical society and the A.M.A. In 
fact, it was one of our local county medical 
societies that introduced a resolution into the 
state society, and then on to the A.M.A., that 
was effective in bringing about a reversal by the 
insurance company in this terribly unprofessional 
attempt to interfere with the doctor-patient re- 
lationship. 

Hospital staffs are fragmented into many hos- 
pitals. Your medical society is made up of all 
the doctors in the community ... or at least 
those who chose to join. In unity there is 
strength. The cacophony of many leaderless 
voices may be ignored. The county medical so- 
ciety can be your ombudsman. Let me urge you 
to join in helping make our society a strong 
group that will represent our views and can act 
to help the physicians in the practice of medicine. 


APRIL, 1973 


333 


Red Cell (Paeked Cell) Transfusions: 

An Appeal to Reason 

JOHN V. PETRUCCI, M.D.* 


The American Association of Blood Banks is 
currently sponsoring workshops throughout the 
country on component therapy and has pub- 
lished a pocket-sized booklet which discusses this 
subject.- At least one hospital in the greater 
Baltimore area has sent a copy of this booklet 
to all its staff members. Despite all of these 
efforts, red cell transfusions are not given as 
frequently as they should be. It is stated by the 
American Medical Association Committee on 
Transfusion and Transplantation that, “It is 
likely that from 60% to 80% of blood trans- 
fusion needs can and should be met by use of 
red blood cells (rather than whole blood ).^ 

Two major objections to the use of red cell 
transfusions are usually raised. 

First objection: The acute loss of whole blood 
should be replaced by whole blood since the 
volume of a unit of red cells is considerably less 
than that of whole blood. 

Obviously, massive acute hypovolemia due to 
blood loss requires replacement by whole blood. 
However, in most cases involving acute blood 
loss, especially surgical blood loss, the loss is not 
massive. I would estimate that in most cases, 
acute blood loss at surgery is no more than 1000 
ml. If this loss were to be replaced with red 
cells, the overall volume difference is only 400 
ml. Usually the patient is also receiving a 
physiological solution during surgery. This can 
easily replace the 400 ml. In fact, the use of 
balanced salt solutions alone is advocated by 
some authors.^ 

The acute loss of 450 ml of blood within six 
to ten minutes carries an infinitesimal risk in a 
healthy adult. Some 6 million individuals a year 
experience such a blood loss, namely blood 
donors. 

Second objection: The surgical patient does 
better with whole blood since he needs the pro- 
teins which are present in the plasma. 

Actually, an average serving of meat or two 
eggs will supply more protein than the plasma 
from one transfusion.^ If a patient truly requires 

* Medical Director, Baltimore Regional Red Cross 
Blood Program, Associate Pathologist, Mercy Hospital, 
Baltimore, Md. 

334 


supplemental proteins, the therapy of choice 
would be salt-poor albumin or purified protein 
derivatives. These products have the great ad- 
vantage of not transmitting hepatitis. 

The ability of an individual to replace his 
proteins is remarkable. It is perfectly safe in 
most instances to remove up to 1000 ml of 
plasma every week for many months in a healthy 
individual. In fact, these are the standards set 
by the American Association of Blood Banks. ^ 

The positive reasons for the use of red cells 
rather than whole blood are many. I will only 
point out the most important ones. 

Most patients who have a red-cell-mass deficit 
do not have a significant plasma volume deficit. 
In fact, they usually have a plasma volume 
excess. In studying the blood volume reports for 
a one-year period at Mercy Hospital, it was 
found that 154 patients had red-cell-mass def- 
icits. The recommended therapy in 152 (98.7%) 
of these patients was red cell transfusions. If 
whole blood were to be used to replace the 
red-cell-mass deficit, 152 of these patients would 
have been overloaded, some to a very sig- 
nificant degree. 

One of the often overlooked reactions to 
blood transfusions is overloading. Although it 
is very difficult to prove, this may be the cause 
of a significant number of deaths. Acute pul- 
monary edema, as we all know, is the immedi- 
ate cause of death in many hospitalized individ- 
uals. 

Most blood transfusions are given to increase 
the patient’s oxygen carrying capacity. Only the 
red cells in blood accomplish this purpose. 

The use of red cell transfusions reduces the 
amount of potassium, sodium, citrate, ammonia, 
and acid transfused. The benefits of this are 
obvious. The transfusion of the waste products 
found in donor blood would also not appear to 
be beneficial. 

If plasma can be salvaged as a result of red 
cell transfusions, it can be frozen and used 
therapeutically in many instances. It can also be 
fractionated into many useful products such as 
albumin. Factor VIII, gamma globulin, hyper- 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


immune globulins, and fibrinogen. The list of 
therapeutic fractions is steadily increasing and 
many fractions are in short supply. Physicians 
charged with the responsibility of treating 
hemophiliacs are surely aware of the shortage 
of Factor VIII concentrate. 

Lastly, since many authorities have urged the 
use of red cell transfusions instead of whole 
blood transfusions, and there are instances 
where whole blood transfusions may be con- 
traindicated, it may soon become a medicolegal 
issue. For instance, could the use of whole 
blood transfusions rather than red cell transfu- 
sions be the grounds for a malpractice suit? 

Sweet Charity 

At least part of the reason some doctors feel 
vaguely dissatisfied with the practice of medicine 
is that it is now almost impossible to be chari- 
table in giving care. A good many are in med- 
icine partially as a result of the attractiveness 
of that image of a kindly, benevolent doctor 
doing kindnesses and generally giving aid and 
helping free-of-charge those so unfortunate as 
to be sick and penniless at the same time. 

That isn’t to say that the same young dreamers 
didn’t know that a good and comfortable living 
could be made in the practice of medicine. But 
there must be more to a job or a career to make 
it satisfying and attractive enough to spend an 
entire lifetime at it. The acquisition of money is 
rarely a good enough reason in itself to spend 
any more that whatever time is required at a 
job to collect enough money for whatever the 
immediate needs might be. 

The opportunity to be a benefactor in any 
endeavor is a subtle enticement and it is this 
that has been partially lost. More money can- 
not make up for this loss. It is not just those in 
the medical profession who feel this loss, but 
we are familiar with and can cite specific illus- 
trations as the issue applies to the practice of 
medicine. 

There is now a penalty affixed to any chari- 
table venture in a doctor’s office through the use 
of fee profiles now kept on every doctor who 
makes charges through any governmental or 
insurance company program. Every time a re- 
duced fee is recorded, the average is reduced 
making it impossible to collect a normal or a 
reasonable fee from someone else about whom 
the doctor need not feel quite so charitable. This 
is probably enough in itself to put an end to any 


REFERENCES 

1. AMA Committee on Transfusion and Trans- 
plantation: Whole Blood Use Called Wasteful, JAMA, 
212:42-44, 1970. 

2. American A.ssociation of Blood Banks: Blood 

Component Therapy, Chicago: Twentieth Century 

Press, Inc., 1969, pp. 1-8. 

3. American Association of Blood Banks: Standards 
for Blood Banks and Transfusion Services, 5th ed., 
Chicago: Twentieth Century Press, Inc., 1970, pp. 19- 
21 . 

Reprinted from Maryland State Medical Journal, 
January, 1971, Vol. 20, pages 61-62. © 1971 by the 
Medical and Chirurgical Faculty of the State of Mary- 
land, Baltimore, Maryland. Printed in U.S.A. 

charitable impulse but when the realization oc- 
curs that the real beneficiary is the federal gov- 
ernment or some insurance Goliath, the impulse 
hasn’t a chance. If the date happens to be about 
April 15th, the impulse is short-lived indeed. 

During the arguments over Medicare it was 
pointed out by the medical profession that many 
millions of dollars worth of free care were being 
given yearly to the aged and that an inevitable 
result to Medicare would be that physicians’ in- 
comes would be increased by government pay- 
ments for what was formerly free. The argu- 
ment was lost. Medicare became law. Another 
avenue for charitable giving became the govern- 
ment’s. Physicians’ incomes, of course, went up 
and physicians were immediately indicted for 
making more money at the expense of the pro- 
gram. The very same thing happened with 
Medicaid. 

It seems the term “charity” is becoming one of 
those strange, archaic and anachronistic words 
like one from Shakespeare or Chaucer. Charity 
is now welfare. The only ones allowed to feel 
charitable anymore are social workers employed 
in a federally-financed program. A shabby 
imitation of a cardinal virtue it must be for 
them, too. 

Preachers speak of charity but seldom prac- 
tice it. The Church, too, has lost its charitable 
role to the government and ecclesiastics medi- 
tate on lost feelings of Christian spirituality. It 
does seem strange that as the traditional concept 
and meaning of charity is destroyed by govern- 
ment, the people lose faith in government, and 
some even hope. 

Reprinted from the 

West Virginia Medical Journal 

Oct., 1971 


APRIL, 1973 


335 




A Brief Look at 
Methadone 
Maintenanee^ 

DAVID H. KNOTT, M.D., PH.D.* * 
ROBERT D. FINK, M.D.** 

Methadone Maintenance has become a use- 
ful adjunct in the treatment of narcotics addic- 
tion and is employed as one of the modalities 
of therapy at the Tennessee Psychiatric Hos- 
pital and Institute. Historically, the hypothetical 
medical rationale for employing a “substitution 
addiction” was based on Dole’s emphasis that 
the addict sustained a physiologic (metabolic) 
abnormality which caused a “narcotics hunger,” 
which, even when he was motivated to be drug- 
free, caused him to seek relief through narcotics. 
Treatment failures, through “talk therapies,” 
with a few notable exceptions, were consid- 
erable and reached proportions sufficient to sug- 
gest that psychotherapy for this patient popula- 
tion was a useless expenditure of time and 
money. Man’s attempts to live better chemically 
fostered by the philosophy of Timothy O’Leary 
and the Vietnam conflict in the late sixties and 
early seventies caused an increasing number of 
addicts to emerge, and the new clinical entities 
now were no longer from the Black ghetto 
but involved every segment of society. Com- 
munities were experiencing astronomical in- 
creases in their crime index and in some urban 
areas 50% of all arrests were drug-related. 

Philosophically, Methadone Maintenance em- 
phasized law abiding and productive behavior 
rather than abstinence per se, and thus had 
great political and social appeal. Dole’s orig- 
inal studies indicated a very favorable trend 
in decreasing felonies and other illegal patterns 
of behavior, along with showing significant, 
positive, social and vocational changes in the 
addict’s life. In Britain forty-four ambulatory 
clinics for dispensing narcotics to addicts were 
established between 1919 and 1923. However, 
until the innovative work of Dole and Nyswan- 

t From the Tennessee Psychiatric Hospital and 
Institute, Alcohol and Drug Dependence Clinic, Mem- 
phis, Tenn. 

* Medical Director 

** Director of Psychiatric Services 

336 


der in 1964, the concept of making a narcotic 
available was not tried in this country. To 
some degree the acceptance of this concept was 
based on significant differences between Metha- 
done and other narcotic agents. Methadone is a 
synthetic narcotic discovered by the Germans 
during World War II as a “spin-off” from the 
research done on Meperidine. 

The qualities of this drug which make it 
applicable for treating the narcotics addicts are, 

( 1 ) , it is an inexpensive, long acting drug last- 
ing for twenty-four hours and thus, can be 
given in a one time a day dosage. (2) Initially, 
it was also described as providing a “blockade” 
against the euphoric effects of opiates (heroin) 
and other synthetic narcotics. This referred 
specifically to the ability of the drug to produce 
tolerance to other narcotic agents and the usual 
dosages of other narcotics are not sufficient to 
overcome this effect. Therefore, it becomes 
senseless for the addict to seek the euphoria 
from other narcotic agents. Thus, the hope of 
Methadone Maintenance is to provide an in- 
expensive, available, legal narcotic which is 
long acting and blocks the euphoric effects of 
opiates and other synthetic narcotics, and it is 
to some degree accomplished by this drug. 

Theoretically, such a program is designed 
to stop the necessity for “copping” (making con- 
tact for purchasing of drugs), the craving for 
narcotics, “dealing” (selling of drugs), and 
anti-social behavior (prostitution, theft, etc.) to 
get enough money to support the addict’s habit. ^ 

The criteria for success include improvement 
in the area of interpersonal relationships (mar- 
riage, parents, friends, etc.), legitimate employ- 
ment (finding a job, less absenteeism, increased 
productivity, fewer job changes), absence of 
legal difficulty, a diminution of drug usage, and 
involvement in a rehabilitation program. These 
parameters emphasize the increase of personal 
responsibility and a change for focus from drug- i 
centered behavior. i 

Patients who apply for admission to our i 
Methadone Maintenance Program must meet ■ 
the following requirements: (1), a documented ; 
history of dependence on one or more opiate ! 

drugs for at least two years; (2), a confirmed ! 

history of one or more failures of treatment 
for their physiological dependence; (3), must | 

be over eighteen years old; and (4), must not ^ 

be psychotic. After the initial Clinic contact, i 
a social history is obtained and verified, and [? 

It; 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION I 


a thorough physical examination, laboratory 
examination, and psychometrics are performed. 
The applicant then goes before an admissions 
committee. If accepted into the Program, he 
signs a contract which commits him not only 
to follow the rules of the Clinic, but which also 
forces him to show improvements in the areas 
of vocational performance and interpersonal 
relationships. 

Patients come on a daily basis to the Clinic 
for their medication, and at this point no carry- 
out Methadone is given. Urine screens are 
obtained on a random basis twice a week. 
Patients who fail to come for medication, along 
with those who have drugs other than Metha- 
done found in their urine screen, are immedi- 
ately contacted and brought before the Metha- 
done Maintenance Clinical Committee for 
reevaluation. An addict who continues to have 
“dirty urines,” missed days from the Clinic 
(failure to come for Methadone), legal diffi- 
culty, or who fails to follow the original con- 
tract, is withdrawn from Methadone and en- 
couraged to seek some other rehabilitation 
program. 

Studies other than ours have indicated that 
lower dosages of Methadone Maintenance (less 
than 50mg. per day) in the motivated patient 
are just as effective as high dose Methadone 
Maintenance (greater than 80mg. per day) in 
the successful participation of the addict in this 
type of program. 

There are many common misconceptions con- 
cerning Methadone Maintenance. One of the 
more common is the difference between Metha- 
done Maintenance and Methadone withdrawal. 
Methadone withdrawal is the process of de- 
toxification of the individual who is addicted 
to narcotics. This process involves initial stabili- 
zation with Methadone and then gradual with- 
drawal over a seven to ten day period, with 
the ultimate goal of reducing withdrawal symp- 
toms and getting the individual to a drug-free 
state. Methadone Maintenance implies an in- 
definite time period where the individual is 
stabilized with Methadone on a prescribed daily 
dosage. Some workers in this field are now 
employing the concept of prolonged Methadone 
withdrawal. The concept of prolonged with- 
drawal involves initial stabilization and mainte- 
nance on a daily dose until the individual has 
begun to give evidence of a positive change 


in his psycho-social rehabilitation; then, over 
a prolonged period of time, anywhere up to one 
year, their maintenance dose is gradually re- 
duced. 

Another misconception concerning Metha- 
done is that it stops all forms of drug de- 
pendence. Certainly the physician should rec- 
ognize that there is no evidence that it alters 
the psychological and physiological effects from 
CNS stimulants, sedatives, hypnotics, hallucino- 
gens, or cannabis derivatives. Some Mainte- 
nance programs have indicated that extremely 
large numbers of their patients abuse alcohol. 
Another confusing area concerns the individual 
who is on Methadone and requires analgesic 
medication either pre- or post-operatively. There 
is ample evidence to indicate that analgesia 
at the usual prescribed dosage provides adequate 
pain relief for the individual who is being main- 
tained. Also, due to the number of deaths 
from Methadone over-dosage in children, be- 
cause of carry-out programs where Methadone 
was given in large amounts to take home, 
the drug has frightened many public health 
authorities. Essentially, Methadone is no more 
toxic or lethal than any other narcotic agent. 
However, due to its prolonged duration of 
action, the individual who takes an over-dose 
of this drug has to be intensively observed for a 
more prolonged period of time than with the 
shorter acting narcotics agents. We have found 
Naloxone Hydrochloride (Narcan) to be the 
antidote of choice for Methadone over-dosage, 
along with indicated symptomatic treatment. 
Though there are many who feel that Metha- 
done is a non-addicting drug, certainly it is 
highly addicting, and according to many of 
our patients, its withdrawal is much more un- 
comfortable and undoubtedly more prolonged 
than that from other narcotic agents. 

Although our Clinic has gathered only pre- 
liminary statistics concerning the effectiveness 
of the Methadone Maintenance Program, we 
feel to some degree encouraged by the improve- 
ment demonstrated in a large percentage of 
our patients. In order to work successfully 
with this patient population, one cannot assume 
that simply supplying Methadone on a daily 
basis solves the problem of the addict. What 
is becoming clear, however, is that many of 
our patients who were inaccessible to psycho- 
therapeutic modalities become more amenable 
once they are stabilized on Methadone. 


APRIL, 1973 


337 


Hoff conference 


John Gaston Hospital* 

ACUTELY AGITATED 
PSYCHOTIC PATIENT 

DR. CHARLES H. HUBBERT: This morn- 
ing we have selected a case for presentation 
because of its illustrative value in differential 
diagnosis and management of the acutely agi- 
tated, aggressive, psychotic patient. Dr. Wilson 
will present the patient. 

DR. JOHN WILSON: The patient is a 42 year old 
black male who was first seen in September and Octo- 
ber, 1971, in the Emergency Room and Neurology 
Clinic, presenting with a chief complaint of “blackout 
spells.” A history of blackouts for approximately five 
\ears was obtained. They were said to occur from once 
a month to twice a week. The episodes were described 
as beginning with nasal stuffiness followed by tachy- 
cardia and diaphoresis and then loss of consciousness 
for several minutes. After regaining consciousness he 
showed mental confusion, disorientation, headache, and 
irritable hostile behavior for several hours. A history 
of tonic-clonic movements was not obtained. 

Physical examination and neurological examination 
in the Neurology Clinic on 10/1/71 showed no ab- 
normalities. Laboratory tests and x-ray studies includ- 
ing CBC, urinalysis, chest film and electrolytes revealed 
nothing remarkable. A lumbar puncture revealed no 
abnormalities, the EEG was interpreted as normal and 
skull films were read as revealing no definite abnormal- 
ities. Because of a blood glucose reported to have been 
47 mg% during the Emergency Room visit a glucose 
tolerance test was done and showed: 30 min. — 94 

mg%, 60 min. — 85 mg%, two hours — 60 mg%, three 
hours — 76 mg%, four hours — 102 mg%, and at five 
hours — 80 mg%. 

The patient was begun on Dilantin 100 mg, t.i.d. and 
phenobarbital 30 mg, t.i.d. He was lost to followup 
until 5/24/72 when he appeared at a community 
health clinic waving a knife and manifesting severe 
psychomotor agitation. He was subdued by eight police- 
men and taken to jail after he slashed the shirt of one 
policeman. He was transferred to John Gaston 
Psychiatric Unit on 5/25/72. Psychiatric examination 
revealed an extremely hostile, agitated and combative 
black male who was extremely uncooperative and 
appeared to be confused and psychotic. After sedation, 
physical and neurological examination was performed 
and revealed no abnormalities. Routine laboratory 
studies and x-ray studies revealed no abnormalities. 
Electrolyte determinations and SMA-12 screening were 
normal. To further evaluate the flat glucose tolerance 
test and to help rule out an insulinoma a tolbutamide 
tolerance test was done and interpreted as normal. 

* From the Department of Psychiatry, University 
of Tennessee College of Medicine, Memphis, Tenn. 


Because of a positive serology (VDRL) of 1-2 dils, a 
lumbar puncture was done and all tests were entirely 
normal, including VDRL. 

The patient’s agitated, psychotic behavior abated 
within four hours of admission after treatment with 
Dilantin 100 mg, t.i.d., phenobarbital 30 mg, t.i.d., 
and chlorpromazine 300 mg, q.i.d. He was amnesic 
concerning the events surrounding his admission. He 
rapidly became cooperative, logical, relevant and co- 
herent. He gave a history of falling out of a window 
during a “spell” one month prior to admission. Later, 
psychological testing revealed findings consistent with 
mild mental retardation without evidence of psychosis. 

Because of the history of onset of apparent seizures 
during adult life, the psychomotor quality of the 
seizures with behavioral changes, and recent history of 
falling out of a window during a seizure, cerebral 
arteriograms were done to rule out surgically correcti- 
ble pathology. A right retrograde brachial arteriogram 
is shown in fig. 1 showing large arteriovenous malfor- 



Fig. 1 — Right retrograde brachial arteriogram showing 
large arteriovenous malformation. 


mation. A followup EEG showing intermixed slowing 
in all leads and more prominently in the temporal 
areas is seen in fig. 2. A technetium pertechnitate brain 
scan was normal, but a cerebral blood flow study 
showed increased flow in the right hemisphere in the 
area of the malformation. 

The patient remained composed without aggressive 
behavior throughout the remainder of his five weeks 
hospitalization except for occasional hallucinations of 
his family standing in the room with him. He realized 
his violent behavior in part but could not understand 
it. His difficulties and findings were discussed with 
him, and the need for continuous regular medication, 
both anticonvulsants and tranquilizers, was impressed 


338 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



T 3 -C 3 ^7*^1 

C3*P3 ^7*^2 

P 3 -O 1 VA, 

V f ^\'^ * ' ' ■ '' y-^'-'’''!^'-' '‘-^'^v//'-^\Vv^v'^A'a' V'’»'~'. 

0 ,-Ts J ' ■ VAj 

VC 4 VA, 

'^V--aa/'A'-'Y\a^WM/Vv i; ; •' ' ''^'Ai'^:yv''^y^V'f'x^^jy\j^f\y^ 

C4-P4 Tg-Aj 

P 4 -O 2 |S 0 >™ • 0|-A, y 

Fig. 2 — EEG showing diffuse intermittent slowing 
compatible with seizure disorder. 

upon him. Because of the findings, charges against 
him were dropped. It was felt that he needed longer 
institutionalization to observe his behavior, possibly 
while not taking tranquilizers, and he was transferred 
to Western State Hospital. 

DR. HAGOP S. AKISKAL: This patient 

exemplifies several important issues which we 
psychiatrists take for granted and rarely pay 
serious attention to. First of all the brain is 
the organ of the mind and behavior. Whether 
abnormal behavior is elicited in response to an 
external stimulus or is the product of an intra- 
cerebral lesion, the final common pathway for 
that particular behavior has to involve neural 
substrates. Also, our treatment modalities work 
through their influence on the brain whether 
directly through drugs and neurosurgery or in- 
directly through psychotherapy. That it is more 
convenient on many occasions to utilize non- 
neural descriptions should not distract us from 
the fact that some patients would benefit 
maximally from somatic investigations. 

The patient under consideration is, in a sense, 
lucky, since he exhibited signs pointing to an 
intracranial lesion, e.g., unconsciousness. How- 
ever, it is not uncommon for patients to present 
without such signs and nevertheless have a 
neurological lesion as the basis for their be- 
havioral aberration. Cases have been reported 
with “purely psychiatric” presentations, e.g., 
hypersexuality, depersonalization, aggressive 
outbursts, and hallucinations, that only years 
later exhibit classical signs of neurologic disease. 
Actually there is not a single symptom of 
schizophrenia — even those regarded as “pa- 
thognomonic” — that cannot be mimicked by 
brain disease. Therefore, this diagnosis should 
always be deferred until all possible causes 


have been reasonably ruled out, e.g., pellagra, 
porphyria, brain tumors, temporal lobe epilepsy, 
alcoholic and drug-related psychoses, etc. At 
an operational level this means that schizo- 
phrenia is reduced to an exclusion diagnosis — 
which would be distasteful to all those who 
claim they know its central feature, be that 
formal thought disorder, blunting of affectivity 
or an “inefficient perceptual filter”. . . 

Secondly, unless a patient is a direct threat 
to his own life or that of others, polypharmacy 
should be avoided. It seems to me that on an 
inpatient psychiatry ward it would have been 
perfectly feasible to start this patient on one 
drug at a time — in this case an antiepileptic 
medication. If he did not respond to one, then 
another or a combination could have been tried. 
Only refractory cases should be approached 
with antipsychotic medications. And in patients 
with an abnormal EEG thioridazine (Mellaril) 
would have been the drug of choice, since it 
has a negligible effect on the seizure threshold, 
while chlorpromazine (Thorazine) lowers it. 
There are three basic reasons why the minimum 
number of drugs compatible with optimum 
therapeutic benefit would be advisable: (a) the 
frequency of side effects would be minimized; 
(b) in case the patient develops pharmacologic 
tolerance to one agent, we will have several 
other agents in our armamentarium; (c) finally, 
should a serious side effect like agranulocytosis 
develop, we would discontinue only one drug — 
but were all the available drugs effective in a 
certain condition utilized, we would have found 
ourselves at a therapeutic impasse. 

Concerning the psychological aspects of this 
case, it seems to me that the finding of an 
“organic lesion” in this patient led the psy- 
chiatry residents who treated him to neglect the 
psychosocial context in which his aggressive 
behavior manifested itself. Such neglect — while 
understandable on the part of neurologists — is 
unpardonable in our field. It is true that this 
man’s aggressive behavior was often manifested 
during the period of postictal confusion, yet at 
othe»’ times such confusion was minimal or not 
documented. It would have been profitable to 
study the interpersonal or sensory stimuli which 
impinged on his damaged neural apparatus and 
elicited aggressive responses. It has been dem- 
onstrated that certain forms of epileptic dis- 
charges either classical epilepsy or atypical sei- 
zures, can be triggered by certain environmental 


APRIL, 1973 


339 


■T> 


f. 

( 

I 

i 

i 


Stimuli. A knowledge of such factors can maxi- 
mize our therapeutic effectiveness in such pa- 
tients. The patients or their relatives should 
be advised that the patient must avoid exposure 
to these offending situations. That our search 
for such factors may be tedious should not 
discourage us. There are situations where 
drugs will fail and patients will require this type 
of management until appropriate neurosurgical 
intervention is instituted. Also, we should keep 
in mind that epileptics can utilize their illness 
in the service of psychodynamic needs, e.g., 
they may mimic seizures to obtain certain social 
rewards (“attention,” the benefits of the “sick 
role”), or they may perform antisocial acts 
with the hope that the latter will be attributed 
to their illness. 

DR. HUBBERT: This case is an example 
of the over-cited case of an erroneously diag- 
nosed psychiatric patient dying of brain tumor 
in the back wards of a state hospital. Though 
organic, and certainly potentially treatable, 
psychiatric syndromes are missed, they are not 
as common as the public — and even nonpsy- 
chiatric physicians — are lead to believe. This 
is not to minimize the psychiatrist’s duty to 
take careful histories and get adequate consul- 
tation when there is doubt about etiology, while 
at the same time treating the patient sympto- 
matically. One could argue that it was the 
neurologist’s obligation to have diagnosed this 
patient. However, too much reliance was paid 
to the patient’s possibly inaccurate history to- 
gether with the report of a normal EEG and 
spinal fluid as well as inadequate cooperation 
on followup. When the patient is required by 
virtue of his hostile, aggressive behavior to visit 
the psychiatrist (through the police depart- 
ment), then the psychiatrist has the opportunity 
to re-open the case. At this time he is able to 
see the patient at the apex of his psychopa- 
thology and gather further history of a recent 
fall which suggests head trauma, namely, a sub- 
dural hematoma. A review of his old record 
showing an Emergency Room visit after a sei- 
zure when a blood glucose of 47 mg% was 
found should alert the psychiatrist to the various 
etiologies of hypoglycemia which is an oft- 
neglected cause of acute behavioral aberrations 
in addition to seizures. Hypoglycemia after 
alcohol abuse is more common than recognized 
and should be thought of, but an insulin-pro- 
ducing tumor though rare would probably be 

340 


considered by many internists called in consul- 
tation. In the past the tolbutamide test using 
blood glucose levels was one of the best tests, 
for insulinoma, but in many places blood in- 
sulin levels are now available and more reliable. 

With the building evidence of organic or 
structural brain disease (EEG now abnormal 
though not specific) the neurology consultant 
is ready for a contrast study after finding the 
CSF studies, including the VDRI normal. An 
unexpected arteriovenous malformation is found, 
and a brain tumor or subdural hematoma is 
ruled out. It is felt that the malformation is 
influencing the temporal lobe, probably as a 
mass, and causing his symptomatology, i.e., 
temporal lobe or psychomotor seizures with 
postictal psychotic behavior. A plausible etiol- 
ogy is now established. The management of 
the malformation, however, is considered to 
be beyond the scope of our present discussion. 

But before leaving all of the reasoning for 
adequate, indepth evaluation of the assaultive, 
aggressive patient, or any other psychiatric syn- 
drome for that matter, one should consider the 
legal implications of such behavior. This pa- 
tient was charged with a serious offense, namely, 
assault with a deadly weapon. A charge of this 
severity of necessity warrants a thorough evalu- 
ation not only psychiatrically but neurologically 
to best answer the question of criminal responsi- 
bility. This question did not arise in this 
patient because charges were dropped after the 
details of this case were known by the au- 
thorities. 

What about the management of this patient 
or any patient who is hostile, aggressive, as- 
saultive, or homicidal regardless of etiology — 
organic or purely psychiatric? The psychiatrist 
is best equipped to handle these persons with 
his vast array of psychotropic drugs and expert 
knowledge of human behavior. The calming at- 
mosphere of a psychiatric ward alone often is 
sufficient to improve such disturbed behavior. 
A major tranquilizer, chlorpromazine, was the 
principal agent used in this patient and probably 
would have been the choice of most. It has the 
advantage of being useable intramuscularly. 
Also, chlordiazepoxide is quite an effective drug 
in large doses for quieting the agitated patient 
on a rapid, short-term basis and might be 
preferable in the elderly, debilitated, or medi- 
cally complicated patient. The use of Dilantin 
in this patient did not produce the prompt 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


improvement in his behavior even though his 
difficulty apparently was initiated by a seizure 
post-ictal state. He had not been on his anti- 
convulsants immediately prior to his outbursts, 
and in all likelihood his Dilantin levels were 
low or absent. The small dose of 300 mg the 
first day of hospitalization would have been in- 
effective in producing specific improvement in 
his behavior. One could even say he would 
have improved spontaneously without any 
therapy once over the post-ictal state. However, 
this possibility should not have influenced the 
use of psychotropic drugs as well as starting 
him on loading doses of Dilantin and pheno- 
barbital. The use of antiparkinsonian drugs 
routinely with phenothiazines is widespread but 
probably should be discontinued except in some 


elderly patients or those more susceptible to 
extrapyramidal signs. These drugs in them- 
selves can and frequently do cause organic brain 
states and psychoses. 

In summary, the psychiatrist is often the 
physician who is first consulted for a patient’s 
change in behavior or personality. Since these 
changes are also the hallmarks of temporal lobe 
or psychomotor seizure disorders, whether pri- 
mary, idiopathic, or secondarily symptomatic of 
other causes, he should be aware of these pos- 
sibilities and seek appropriate consultation while 
giving emergency treatment to the patient in a 
manner for which he has been expertly trained. 
An example of such a case has been presented 
and several aspects of his case have been elab- 
orated on. 


SAINT 

ALBANS 

PSYCHIATRIC HOSPITAL 

Radford, Virginia 


STAFF: 

James P. King, M.D. 

William D. Keck, M.D. 

Morgan E. Scott, M.D. 

David S. Sprague, M.D. 

Edward E. Cale, M.D. 

Delano W. Bolter, M.D. 

Tericild 

Vinding, M.D. 

Clinical Psychology: 
Thomas C. Camp, Ph.D. 
Carl McGraw, Ph.D. 

Don Phillips, Administrator 

George K. White 
Asst. Administrator 


APRIL, 1973 


341 



THE COOPER QUIZ* 

(answers to be found beginning on p. 394) 

True or false except as indicated. 


1 . Ambulatory patients with chronic alcoholism who had no symptoms or signs and no EKG 
or x-ray abnormalities indicating heart disease do have cardiac malfunction, 

2. Mechanical ventilation may deplete the lung of surfactant, which is of serious consequence. 
With the possible exception of the premature infant, surfactant deficiency is the result, not 
a cause of alveolar damage. 

3. In the USA infections with Entameba histolytica are primarily asymptomatic in the form of 
the intestinal carrier state. 

4. There is evidence that L-dopa administration (long term) to patients with Parkinsonism re- 
sults in an increase in the growth hormone in the plasma. Because of this fact these patients 
should be checked for the development of acromegaly. 

5. Death from heatstroke is not uncommon. Approximately (30) (50) (65) (80) percent of 
these patients die from acute circulatory failure. 

6. Restoration of body temperature to normal in heatstroke victims is as important as support of 
the cardiovascular system. 

7. Patients with psoriasis, besides being influenced by heredity, also have an increase in HL-A13 
antigens. 

8. Cytomegalovirus (CMV) can be transmitted via semen. 

9. Hypertension is the most important etiologic factor in congestive heart failure. 

10. In a Cook County (Illinois) study of infantile diarrhea, 80 percent of the cases did not yield 
a specific pathogen. 

11. The toxic effects of marihuana are related to the acute happenings at the time of its use. 
There appears to be no effects from chronic use per se, 

12. Besides dogs and other canines, bats are the only animal that constitutes a threat in the in- 
fection of rabies. 

13. In a Canadian study of patients receiving digitalis (5) (12) (23) (29) percent developed 
intoxication. 

14. “Abdominal epilepsy” is, in reality, a nonentity. 


* We are indebted to William T. Snagg, M.D., Director of Medical Education, The Cooper Hospital, for 
permission to reprint portions of “The Cooper Quiz.” Published monthly by the Dept, of Medical Education, 
The Cooper Hospital, Camden, N.J. 08103. 


342 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


15. The “battered child” may be the result of a “battering child” rather than an adult. 

16. One authority lists 7 basic contraindications for organ donation. Can you name 4 of them? 

17. Of the drugs that cause a syndrome resembling systemic lupus, procainamide is probably the 
worst offender. 

18. Hidradenitis suppurativa is basically an inflammatory reaction of the subaceous glands result- 
ing in abscesses, draining sinuses and hypertrophic scar tissue. 

19. In type IV hyperlipoproteinemia cloflbrate given without dietary restriction resulted in lower- 
ing both the triglycerides and the cholesterol. 

20. In a New York study with anticoagulation therapy for acute myocardial infarction (1) (men) 
(women) seemed to benefit more than (2) (men) (women). 

21. A study of the treatment of acute pulmonary edema in an intensive care unit or on the regular 
hospital floors yielded only one bit of difference. The cost to the patient was higher in the unit 
but mortality rate was the same. 

22. Pleural effusions are divided into “transudates” and “exudates.” In the transudates the pleural 
surfaces are not thought to be involved in the primary pathologic process. The exudates are 
results from inflammation or other disease processes of the pleural surface. 

23. The protein content of the effusion is an effective and accurate way to distinguish between 
transudates and the exudates. 

24. If the pleural fluid is (transudate) (exudate) further diagnostic procedures are imperative to 
reach a definitive diagnosis and start specific therapy. 

25. Mitochondrial antibody was detected in the serum of a high percentage (84) of patients with 
primary biliary cirrhosis but not in patients with acute or chronic viral hepatitis. 

26. The test for mitochondrial antibody may not prove to be an accurate method of confirming 
the diagnosis of primary biliary cirrhosis because of the number conditions in which it is 
found. 

27. Thyroid hormone treatment for myxedema has generally been unsatisfactory because of a high 
mortality rate. 

28. Thiazide diuretics (raise) (lower) urinary calcium excretion. 

29. Thiazide diuretics do not lead to hypercalcemia if the patients are given vitamin D. 

30. The nephrotic syndrome with morphologic features of normal, or near-normal, glomeruli by 
light microscopy is well known; it is sometimes called “lipoid nephrosis,” “idiopathic” or 
“minimal change” nephrotic syndrome. Most patients respond to steroid therapy with cessa- 
tion of proteinuria. 

31. Hydrochlorothiazide (50 mg bid per 25 days) will significantly (increase) (decrease) plasma 
calcium. 

32. Quinidine can be hepatotoxic. 


APRIL, 1973 


343 


A 





topic/ in nudeor mc«Nci 

. /' 



The Use of Xenon Gas 
In Nuclear Medicine* 

Part II 

Cerebral Blood Flow Studies 

In 1948, Kety and Schmidt^ used the inert 
gas, nitrous oxide, to measure total cerebral 
blood flow. The method involved sampling 
blood from the arteries supplying the brain 
and from the veins draining the brain and 
utilized the concept of the partition coefflcient 
(ratio of concentration of gas in tissue/con- 
centration of gas in blood). In 1955, Lassen^ 
utilized radioactive ^-^Krypton to measure cere- 
bral blood flow and in 1963, Glass and Harper^ 
used radioactive ^^^Xenon for the same purpose. 
The rationale for using a gamma emitting, inert, 
diffusible gas is that it can be measured ex- 
ternally, that it equilibrates between blood and 
brain in some known proportion (the partition 
coefficient), and that it washes out of the brain 
as blood that contains little or no xenon per- 
fuses the brain, the rate of washout being a 
direct measure of the rate of blood ffow. Re- 
circulation of xenon was not considered sig- 
nificant since, in one passage through the lung, 
90 to 95% of xenon in venous blood passes into 
alveolar air and is promptly exhaled. The va- 
lidity of the method depends upon the accuracy 
with which the partition coefficient can be calcu- 
lated, the accuracy with which the photopeak of 
^•‘^•^Xenon can be measured, the extent to which 
anatomic variables can be appreciated, and, of 
course, the overall reproducibility of the wash- 
out curves. 

Partition coefficients for xenon present a par- 
ticularly difficult problem. The distribution of 
xenon between blood and tissue is dependent 
upon hemoglobin levels."^ Furthermore, it is 
significantly different in white matter and grey 
matter and is unknown for abnormal brain 
tissue.® With a hemaglobin of 8 grams%, the 
partition coefficient is 1.76 for white matter 
and .94 for grey matter, while, with a hemo- 
globin of 17 grams %, it is 1.44 for white matter 
and .77 for grey matter. If fat surrounds the 

* From the Department of Nuclear Medicine, Park 
View Hospital, Nashville, Tenn. 


organ of interest (i.e. subcutaneous fat of the 
scalp), then the very high partition coefficient 
of 8 for faF would lead to a significantly lower 
calculated value for blood ffow through the 
organ if even a small amount of xenon perfused 
that fat. 

The low gamma energy of the 8 1 KEV photo- 
peak of ^®®Xenon presents a very severe prob- 
lem since Compton scatter in soft tissue is such 
that 55% of the activity detected by the probe 
may not come from the geometric area under 
the probe.® Although this may be reduced to 
13% with maximal discrimination, it certainly 
would be higher when passing through dense 
tissue like the bones of the skull. Compton 
scatter may account for the absence of published 
reports of zero flow in areas of total infarction 
and is a serious limitation when trying to re- 
solve fine anatomic detail. ^^"^Xenon might help 
in overcoming this problem of Compton scatter. 

A number of anatomic factors also influence 
the accuracy and reproducibility of regional 
cerebral blood flow studies with xenon. At any 
hemoglobin level, the partition coefficient is 
based on an average ratio of grey to white 
• matter of 60%. However, this ratio varies from 
78% in the anterior temporal region to 34% 
in the posterior frontal region^ and will result 
in an error in any calculation which is based on 
a single compartmental method of analysis.® 

Since there are multiple arteries supplying 
brain, selection of a single internal carotid 
artery for a xenon injection may result in in- 
sufficient tracer material perfusing brain tissue 
that is supplied mainly by another artery. Then, 
even though washout may be rapid, total activity 
may be so low in the region of interest that 
statistical accuracy is compromised. In addition, 
even with a good injection via catheter into the 
internal carotid artery, enough isotope will get 
into the external carotid vessels so that the 
external carotid flow would constitute approxi- 
mately 10% of the total cerebral blood flow.^ 

In severe chronic obstructive pulmonary dis- 
ease a tenfold reduction in the rate of xenon 
elearance from the lung can lead to relatively 
elevated blood levels of xenon. This would lead 
to falsely low cerebral flow values because of 


344 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


extracranial contamination and because of rel- 
atively high blood levels in the intracranial 
vessels. 

While the diffusible tracer method is suppos- 
edly not affected by vascular flow, it is a fact 
that blood flow is elevated in the area of an 
arteriovenous malformation, over the area of 
a carotid siphon,^ or in the tissue peripheral 
to an infarction where one sees “luxury per- 
fusion syndrome” or “red vein syndrome. If 
this non-nutritional blood flow significantly 
affects blood flow calculations with diffusible 
tracers like ^^^Xenon (as appears to be the 
case), it does not necessarily mean that the 
concepts are incorrect. Instead, it may mean 
that an agent with a higher partition coefficient 
or an isotope and detecting system with better 
resolution is needed. 

There are three methods of analyzing radio- 
xenon clearance curves in brain; the stochastic 
height over area method, the initial two minute 
slope method, and the two slope compartmental 
method. Each method has its proponents and 
detractors. Some think that the stochastic 
method is too insensitive and gives values that 
are too low while others feel that the slope 
method of analysis provides a family of slopes 
and that it is almost a guessing game to de- 
termine which slope to use. In control patients, 
Paulson found that the interregional cofficient 
of variation was 8.5% for the stochastic method 
and 10.6% for the two minute initial slope 
method. Mathew et aP found that in ischemic 
patients it was 13% for the stochastic method 
and 24% for the two minute initial slope meth- 
od. These values would be still worse if 30 
or 40 small areas of brain were analyzed 
instead of only 6 to 10 larger areas. If one 
wishes to acquire data with enough accuracy 
and reproducibility to remain within the 95% 
confidence limit, then all of these methods of 
analysis hare an unacceptably wide range of 
values. 

If partition coefficients for xenon are too 
variable and generally too low for the produc- 
tion of reproducible accurate data. 

If the Compton scatter from ^^^Xenon is so 
high that data with poor accuracy is produced. 

If anatomic variables such as focal intra- 
cerebral shunts, variations in distribution of 
grey and white matter, multiple arterial supply, 
chronic obstructive pulmonary disease, and a 
large amount of subcutaneous fat all contribute 


to the production of inaccurate data. 

And if all the methods of analysis of clearance 
curves result in data with poor reproducibility. 

Then it is hard to see how even the most 
sophisticated computers could take all this poor 
data and produce reliable scientific interpreta- 
tions. 

Finally, since the xenon cerebral blood flow 
methodology not only suffers from poor repro- 
ducibility but also is a traumatic and invasive 
method, it is patently clear that it is not a test 
that is suitable for routine clinical use. 

Robert L. Bell, M.D. 

Director 

REFERENCES 

1. Kety, SS, Schmidt, CF: The nitrous oxide method 
for the quantitative determination of cerebral blood 
flow in men. J Clin Invest, 27:476, 1948. 

2. Lassen, NA, Munck, O: The cerebral blood flow 
in man determined by the use of radioactive Krypton. 
Acta Physiol Scandinav, 33:30, 1955. 

3. Glass, HI, Harper, AM. issxenon as a tracer 
for the measurement of cerebral blood flow. Brit Med 
J, 1:593, 1963. 

4. Conn, HL, Jr. Equilibrium distribution of radio- 
xenon in tissue: Xenon-hemoglobin association curve. 
J of Applied Physiology, 16:1065, 1961. 

5. Conqvist and Agee. Regional cerebral blood flow 
in intracranial tumors. Acta Radiologica, 7:393, 1968. 

6. Potchen, EJ, Davis, DO, Wharton, T, Hill, R 
and Taveras, JM. Regional cerebral blood flow in 
man. Arch Neurol, 20:378, 1969. 

7. Wilkinson, IMS, Bull, JWD, DuBoulay, GH, et al. 
Regional blood flow in the normal cerebral hemisphere. 
J Neurol Neurosurg Psychiat, 32:367, 1969. 

8. Rees, JE, et al. The comparative analysis of 
isotope clearance curves in normal and Ischemic brain. 
Stroke, 2:444, 1971. 

9. Mathew, NT, Meyer, JS, Bell, RL, Johnson, PC, 
Neblett, CR. Regional cerebral blood flow and blood 
volume measured with the gamma camera. Neuro- 
radiology, 4:133, 1972. 

10. Prosenz, P, Heis, W, Kvicala, V, Tschabit- 
scher, H. Contribution to the hemodynamics of arterial 
venous malformations. Stroke, 1:219, 1971. 

11. Potchen, EJ, Bentley, R. Gerth, W, Hill, RI, 
Davis, DO. A means for the scintigraphic imaging of 
regional brain dynamics. Proceedings lEAE Sym- 
posium Medical Radioisotope Scintigraphy. 1970. p. 
577-583. 

12. Hoedt-Rasmussen, et al. Regional cerebral blood 
flow in acute apoplexy; the luxury perfusion syndrome 
of brain tissue. Arch Neurol, 17:271, 1967. 


APRIL, 1973 


345 


^ ffom the lenfie//ee dcpcifliiiefil 

of public heollh ^ 




The Role of the Division of Dental 
Health Services in a Public 
Preventive Dental Program 

INTRODUCTION . While man in this mod- 
ern, civilized era has made great strides and ad- 
vancements in the betterment of overall health, 
civilization has brought about the opposite effect 
on the health of the dentition. Probably this is 
caused partially by the composition and texture 
of the modern day diet. Also, while man seems 
to have learned the importance of personal 
cleanliness in relation to general health, he still 
has not been sufficiently motivated in the re- 
lationship of good oral hygiene to dental health. 

PROBLEM. The dental diseases are some of 
mankind’s most prevalent chronic diseases, and 
therefore present a major public health prob- 
lem. In Tennessee the average first grader in 
a nonfluoridated community will have one de- 
cayed, missing or filled permanent tooth and 
five decayed, missing or filled primary teeth. 
By age 14 this same child can expect to have 
one-fourth of his teeth attacked by dental caries. 
Also, recent surveys in Tennessee have shown 
that 85.5% of the children aged 6-14 are af- 
fected with peridontal disease, while 86% are 
affected with dental caries. The National Health 
Survey found that between 1960 and 1962 
approximately 75% of the adult population at 
risk had peridontal disease and 25% had 
destructive peridontal disease. About one-half 
of the school age population needs some kind 
of orthodontic treatment, and one out of five 
high school age children has a severe ortho- 
dontic problem. 

In Tennessee, surveys have shown that about 
6% of elementary school children ages 6-14 
have one or more incisor teeth that have been 
fractured due to accidents. 

Oral cancer is detected in 20,000 people each 
year, and 7,000 persons die yearly from oral 
cancer. One out of every 40 cancer deaths is 
due to oral cancer. 

Cleft lip and palate make up 13% of all 
birth anomalies. 

PLAQUE CONTROL. Many leading dental 
professionals portray plaque control programs 
as preventive dentistry. 

346 


Plaque control programs play a part in a 
broad preventive dentistry program, but they 
should be in proper perspective. The home 
care plaque control program’s success depends 
on the continued involvement of the patient. 
The number who are able to follow such strict 
regimen is a small fraction of the total number 
of Americans needing dental care. A far more 
promising approach to plaque control is to in- 
tensify individual treatments on patients who 
are maximally susceptible to prevention. The 
likelihood of finding a single preventive mecha- 
nism which is epidemiologically universal is 
very slight, in spite of the fact that many seem 
to think that plaque control programs are just 
that. 

As behavioral scientists report, a more 
realistic method of prevention would be to 
identify categories among the population which 
are susceptible to different approaches and then 
select treatments which are most likely to suc- 
ceed because they closely match the patient’s 
total need. Patients in this case can be either 
individual or community. 

It is correct that plaque control answers a 
need not covered by fluoride, sealants, or other 
preventive programs, and has a place in indi- 
vidual practices and in public health programs. 

FLUORIDATION . The most effective, ef- 
ficient and well documented program for the 
prevention of dental caries is still community 
fluoridation. The present benefits of fluoridation 
for caries control probably exceed the maximum 
possible benefit of plaque control home care. 

In the State of Tennessee 213 communities 
fluoridate their public water supplies, serving 
approximately 2Vi million people. 

The first community in Tennessee to fluori- 
date was Milan in 1951. To date every com- 
munity in Tennessee of over 10,000 population, 
with the exception of one municipality, either 
has fluoridated or is in the process of fluori- 
dating. Knoxville, the only major metropolitan 
area in our state without fluoridated water, ap- 
proved fluoridation by referendum in November 
1972, and is in the process of initiating this 
important health measure. Through the con- 
certed efforts of both the private and public 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


sectors of dentistry in this state. Approxi- 
mately two-thirds of all Tennesseans, excluding 
Knoxville drink fluoridated water, and approxi- 
mately 80% of those on a public water system 
drink fluoridated water. 

Several years ago it was determined that while 
we were making great strides in our fluoridation 
program in the larger communities, there was 
a lag in the small communities, or those under 
10,000 population. When finances were de- 
termined to be the major barrier, Tennessee 
initiated the first program in the country to 
offer financial assistance to small communities 
to fluoridate. The State pays 50% of the initial 
cost of fluoridating the water supply of small 
communities, more than 40 of which have 
fluoridated with the assistance of State financing. 

WATER SURVEILLANCE. Some time ago 
the Environmental Protection Agency surveyed 
a sampling of Tennessee’s public water systems 
and found that less than half of them were 
fluoridating at the optimal level. As a result 
of this survey seminars have been conducted 
around the state to train water plant operators 
in better methods of surveillance of the fluoride 
content in their finished water. Further, six 
months ago the Division contracted with the 
National Institutes of Health to place a Sani- 
tary Engineer on the staff to work full-time 
in the area of fluoridation. This is thought 
to be the only Dental Division in a State De- 
partment of Public Health in the country to 
have a full-time engineer on its staff. Addi- 
tionally, funds were made available through 
this contract to provide 100% financial assis- 
tance to 10 small communities across the state 
to initiate fluoridation, in order to determine 
whether more small communities will initiate 
fluoridation if financial barriers are completely 
removed. 

SCHOOL FLUORIDATION. Another new 
program which was begun as a result of the 
contract mentioned above was the addition of 
school fluoridators on 24 school water systems 
which are not on a fluoridated public water 
supply. This project is designed to see if school 
fluoridation achieves the same success in Ten- 
nessee as it has in North Carolina and other 
states. It has been found that dental caries 
can be reduced by one -third in those school- 
age children who drink fluoridated water in 
the concentration of 4 to 5 parts per million 
only during school hours. 


It has been found in the Children’s Dental 
Health Project conducted in Southeast Ten- 
nessee that the cost of providing dental treat- 
ment to children in fluoridated areas is 60% 
less than in non-fluoridated areas. This is of 
great importance when considering the expense 
involved in providing dental care in the Medic- 
aid program or any other governmental pro- 
gram in the future. 

DENTAL HEALTH— EDUCATION AND 
RESEARCH. In addition to community fluori- 
dation, the Division of Dental Health Services 
provides topical fluoride programs to children 
in those areas that do not have the benefits of 
fluoridated water. In these areas self-applied 
fluoride programs are also conducted which 
include teaching good oral hygiene, providing 
a topical fluoride treatment, and giving chil- 
dren a toothbrush and the necessary materials 
to continue good oral hygiene at home. 

Between 40,000 and 50,000 children are 
seen each year on these programs. Some 
plaque control programs are carried out in 
areas where there are teachers or others inter- 
ested enough for success. 

Another classical study conducted by the 
Dental Division in the early 50’s determined 
the relationship between the frequency of eat- 
ing between meals and caries experience. The 
study, which is still widely quoted in the sci- 
entific literature, demonstrated a direct and con- 
stant relationship between caries experience and 
the frequency of eating items of high sugar 
content or a high degree of adhesiveness be- 
tween meals. 

The Dental Division staff currently is con- 
ducting a study of the two most popular sealants 
available commercially to determine their role 
in a preventive program. Other studies have 
shown that the adhesive coverage of the seal- 
ants remained intact on 87% of the permanent 
tooth surfaces after 2 years, with a very low 
percent of treated permanent tooth surfaces 
becoming carious. This procedure appears very 
promising in the area of preventive dentistry. 

Surveys conducted over the years have dem- 
onstrated that the public preventive programs 
of the Division of Dental Health Services re- 
garding dental caries have been effective. The 
caries rates in school-age children (ages 6-14) 
have been reduced from a decayed, missing, 
filled permanent teeth rate of 4.6 to a DMFT 
rate of 2.7 over the past 15 to 20 years. 


APRIL, 1973 


347 


Many supervised toothbrushing programs 
have been initiated in school systems through- 
out the state. At a certain time during the 
day all students in the classroom go through 
a toothbrushing exercise using their own brushes, 
pastes, etc., that are kept permanently in the 
classroom. Thousands of children throughout 
the state are now participating in these super- 
vised toothbrushing programs. 

Early detection and early treatment are the 
answers for decreasing deaths from oral cancer. 
Oral exfoliative cytology has evolved as a po- 
tential aid in early detection of squamous cell 
carcinoma. The Dental Division a few years 
ago cooperated with the College of Dentistry 
at the University of Tennessee in conducting 
seminars across the state to instruct members 
of the dental profession in its use and to en- 
courage them to be continually on the lookout 
for suspicious oral lesions which would hope- 
fully lead to early diagnosis and treatment of 
oral cancer. 

Since there is probably more misinformation 
in the field of dental health than any other 
health area, a public preventive program must 
include dental health education. The Dental 
Division, along with the L. G. Noel Memorial 


Foundation and the Department of Education, 
has developed the Dental Health Guide for 
Teachers of Tennessee, which has been distrib- 
uted to school systems throughout the state. 
The Guide has been used and copied through- 
out the United States and has been distributed 
internationally. The staff of the Dental Division 
works with teachers and other educational per- 
sonnel to provide up-to-date factual information 
on dental health to all students. 

SUMMARY. There are two ways of coping 
with the dental disease: corrective treatment 
and prevention. Prevention, which is the major 
thrust of the Dental Division, is more pro- 
ductive and less costly. 

The purpose of dental public health pro- 
grams in Tennessee is to maintain and improve 
the dental health of the people of the state by 
prevention of dental diseases by utilization of 
all the scientifically proven methods, education 
of people at all levels of our society, the pro- 
vision of dental treatment to those unable to 
provide dental treatment for themselves, and 
conducting a limited number of demonstration 
and research projects. 

Durward R. Collier, D.D.S., M.P.H 





HOSPITAL 


A non-governmental psychiatric hospital. Accredited 
by Joint Commission on Accreditation of Hospitals. 
Medicare Approved. Phone: 205 — 836-7201 


Hill Cresf Foundation, Inc. 


A short-term, intensive treatment center for psychiatric 
disorders, alcoholism, and drug abuse. 

PSYCHIATRISTS: Member of: American Hospital Association, Na- 

James K. Ward, M.D. tional Association of Private Psychiatric Hospitals, 


. M.D. 

Hardin M. Ritchey, M.D. 

F. Joseph Nuckols, M.D. 
James A. Greene, M.D. 
Charles W. Moorefield, M.D. 


Birmingham Regional Hospital Council. 

6869 FIFTH AVENUE SOUTH 
BIRMINGHAM, ALABAMA 35212 


348 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



r 

L 



j|f®pBf'''''''" 




of Ihe fflofilh 


HISTORY 

This 23 year old lady was hospitalized for evaluation 
of recurrent episodes of palpitation. Although no dis- 
turbance of heart rhythm had been documented electro- 


cardiographically, her description of abrupt self limited 
episodes of rapid heart action seemed real. Her family 
physician was convinced of her emotional stability 
and requested consultation regarding a suspected or- 
ganic basis for her complaints. Physical examination, 
chest x-ray and routine laboratory tests including PBI 
were normal. Her resting electrocardiogram is illus- 
trated. Although cardiac rhythm is normal, a clue is 
afforded as to the likelihood and nature of a paroxys- 
mal arrhythmia as the basis of her symptoms. 



DISCUSSION 

The electrocardiogram is normal except for 
a shortened P-R interval of 0.08 sec. The 
normally expected P-R interval is 0,12-0.20 sec. 
This time interval represents normal delay of 
electrical conduction between the atria and ven- 
tricles through the atrioventricular (A-V) junc- 
tion. An abnormally short P-R interval com- 
monly represents accelerated AV conduction. 
Another situation which may result in ab- 
normally short PR intervals is isorhythmic A-V 

From the Department of Cardiology, St. Thomas 
Hospital, Nashville, Tenn. 


dissociation. A-V dissociation is unlikely in this 
tracing as no variation in P-R interval is noted 
throughout the tracing. (Repeat electrocardio- 
grams in the patient showed no change.) 

The various P-R interval and QRS patterns 
of accelerated AV conduction may be associ- 
ated with specific anatomic anomalies of the 
conduction system, A short P-R interval with 
initial slurring of the QRS complex (Delta 
wave) may be ascribed to direct short circuits 
between the atria and ventricular myocardium 
by Kent bundles (small bridges of tissue across 
the fibrous A-V ring), and represents the 


APRIL, 1973 


349 


familiar Wolft'-Parkinson-White syndrome. A 
similar QRS pattern with normal P-R interval 
has been described and may be associated with 
fibers described by Mahaim which short circuit 
the bundle of His or proximal bundle branches 
with immediately adjacent ventricular myocar- 
dium. 

The electrocardiogram above represents a 
third possibility, that of a short circuit from 
the atria into the conduction system below the 
AV junction without direct myocardial connec- 
tions, Such a possibility exists in the occasion- 
ally observed histologic finding that fibers from 
the posterior intranodal pathway extend distally 
by passing the A-V node to connect directly 
with the His bundle. These fibers have been 
described in detail by Dr. T. N. James and 
not only represent a mechanism for a short 
P-R interval with normal intraventricular con- 
duction, but also represent a potential pathway 
for re-entrant tachyarrhythmias.^ The association 


of short P-R interval, otherwise normal electro- 
cardiogram and recurrent tachyarrhythmias 
were recognized in 1952 by Town, Genong and 
Levine.^ This young lady would appear to rep- 
resent an example of this problem. 

FINAL EKG DIAGNOSIS: Accelerated AV 
conduction of the “James fiber” type with as- 
sociated paroxysmal tachyarrhythmias (Lown- 
Genong-Levine syndrome). 

W. Barton Campbell, M.D. 

Harry L. Page, Jr., M.D. 

Co-Directors 

REFERENCES 

1. James, TN: Morphology of the Human AV 

Node with Remarks Pertinent to its Electrophysiology. 
Amer Heart J, 62:756, 1961. 

2. Lown, B, Genong, WE, Levine, SA: The Syn- 
drome of Short PR Interval, Normal QRS Complex 
and Paroxysmal Rapid Heart Action. Circ. 5: 693-706, 
1952. 




❖ 


REFER EYE PATIENTS 

TO AN 

EYE PHYSICIAN 

By so doing, you will be assured of a complete diagnosis of your 
patients’ eyes. 

Guild Opticians complete the cycle for Professional Service. 





BE SAFE-BE SURE 
SEE 

YOUR GUILD OPTICIAN 
FOR 

THE BEST SERVICE 
EYE PHYSICIANS: Please Note- 

Your prescriptions for glasses are "SAFE" when referred to a Guild Optician. 
Bound by the code of Ethics to uphold the highest standards in optical service. 


350 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



kibofcilom micHciiM 


Australia Antigen and 
Post-Transfusion Hepatitis 

The clinical aspects of the complicated rela- 
tionship of the “Australia antigen” (here re- 
ferred to as HBAg, for “hepatitis B antigen”) 
to viral hepatitis are gradually becoming clari- 
fied. This antigen may in fact be the viral agent 
of “serum” hepatitis; a virus of similar etiologi- 
cal significance to “infectious” hepatitis (hepa- 
titis A) has to date not been identified. The 
clinical implications of exposure to HBAg may 
range from incidental discovery of the antigen 
in an entirely asymptomatic blood donor to 
fulminant and fatal hepatitis. Antigenemia may 
be transient, or persistent in a “carrier” state, 
the latter situation occurring with all gradations 
of liver disease from none to chronic hepatitis 
with cirrhosis. 

The significance of HBAg relative to post- 
transfusion hepatitis (PTH) is still under investi- 
gation, and much has been learned. Overall, 
it has been estimated that 30,000 cases of trans- 
fusion-associated overt hepatitis (and perhaps 
150,000 cases of subclinical hepatitis) occur 
annually in this country, resulting in 1500-3000 
deaths. From information compiled before the 
current practice of excluding HBAg-positive 
units of blood from transfusion purposes, the 
risk of developing PTH from a unit of HBAg- 
positive blood is three to five times greater than 
from an HBAg-negative unit. Approximately 
15-30% of recipients of a single unit of HBAg- 
positive blood may develop overt hepatitis. 
Similarly, a given blood donor may be impli- 
cated in disease transmission in only a few 
instances of PTH, though he may have donated 
multiple, presumably infective, units over a 
period of time. These facts suggest that a given 
unit of blood may be hazardous for some, but 
not all, recipients. 

HBAg may be detected, depending on the 
test method, in about 1% of an overall donor 
population in the United States. However, the 
incidence of antigenemia may be from two to 
fifteen times higher in a paid donor population 
than in volunteer donors; accordingly, the in- 
cidence of PTH in recipients of blood from 
the former group compared to the latter is 


several times higher (5.3% versus 1.5% in 
one recent large study). Factors implicated 
in the increased incidence of HBAg-positivity 
in paid donors are a generally lower socio- 
economic status and a significant incidence of 
drug abuse. Other potential high-risk donor 
populations include health care personnel and 
previously transfused individuals. Interestingly, 
persons with a history of hepatitis may not 
be at any greater risk than those without such 
a history, although in practice they are gen- 
erally eliminated as blood donors. 

The presence of the antibody to HBAg (anti- 
HBAg) is indicative of previous exposure to 
the antigen, and, employing relatively insensi- 
tive laboratory techniques, may be detected in 
about 0.1% of blood donors. The incidence 
is much higher in multiply-transfused recipients 
(hemophiliac plasma is the commercial source 
of this antibody). Although in current prac- 
tice it is generally excluded from use in trans- 
fusion, blood containing this antibody may not 
in fact be any more likely to transmit hepatitis 
than blood containing neither HBAg nor anti- 
HBAg. 

Statistics emerging from various studies indi- 
cate that donor screening and elimination of 
all HBAg-positive units may significantly de- 
crease the incidence of PTH. Whereas the rel- 
atively insensitive agar-gel diffusion method will 
detect roughly 30% of HBAg carriers, more 
sensitive techniques (e.g., complement fixation) 
may double this figure. The use of radioim- 
munoassay, which will be widely employed in 
the future, and hemagglutination-inhibition, al- 
though ten times more sensitive than comple- 
ment fixation, may increase the detection rate 
by only a relatively small percentage. 

The problem that remains is that there is 
still a substantial percentage of cases of PTH 
that, at the present time, cannot be predicted 
or prevented. It is estimated that roughly 65% 
of PTH may be due to hepatitis B; of this figure, 
greater than half may be prevented by elimina- 
tion of all HBAg-positive donor units. This still 
leaves the 35% of cases unrelated to hepatitis 
B, plus the inevitable percentage of HBAg car- 
riers with antigen levels too low for detection 


APRIL, 1973 


351 


but still infectious. The judicious use of blood 
and blood components, restricted to those ob- 
tained from low-risk, HBAg-negative carefully 
screened volunteer donors, is the best policy 
that can be employed in the light of our current 


understanding of this intriguing problem. 

Dean G. Taylor, M.D. 

Laboratory Service, Methodist Hospital 
Memphis, Tenn. 38104 


Pillars of Economic Wisdom 

Just imagine what kind of economy we could 
enjoy if we lived according to these principles: 

1. Nothing in our material world can come 
from nowhere or go nowhere, nor can it be free. 
Everything in our economic life has a source, a 
destination and a cost that must be paid. 

2. Government is never a source of goods. 
Everything produced is produced by the people, 
and everything that government gives to the peo- 
ple, it must first take from the people. 

3. The only valuable money that government 
has to spend is that money taxed or borrowed 
out of the people’s earnings. When government 
decides to spend more than it has thus received, 
that extra unearned money is created out of 
thin air, through the banks, and, when spent, 
takes on value only by reducing the value of all 
money, savings and insurance. 

4. In our modern exchange economy, all 
payroll and employment come from customers, 
and the only worthwhile job security is customer 
security. If there are no customers, there can be 
no payroll and no jobs. 

5. Customer security can be achieved by the 
worker only when he cooperates with manage- 
ment in doing the things that win and hold 


customers. Job security, therefore, is a partner- 
ship problem that can be solved only in a spirit 
of understanding and cooperation. 

6. Because wages are the principal cost of 
everything, widespread wage increases, without 
corresponding increases in production, simply 
increase the cost of everybody’s living. 

7. The greatest good for the greatest number 
means, in its material sense, the greatest goods 
for the greatest number which, in turn, means 
the greatest productivity per worker. 

8. All productivity is based on three factors: 
a) natural resources, whose form, place and con- 
dition are changed by the expenditure of b) 
human energy (both muscular and mental), with 
the aid of c) tools. 

9. Tools are the only one of these three fac- 
tors that man can increase without limit, and 
tools come into being in a free society only 
when there is a reward for the temporary self- 
denial that people must practice in order to 
channel part of their earnings away from pur- 
chases that produce immediate comfort and 
pleasure, and into new tools of production. Prop- 
er payment for the use of tools is essential to 
their creation. 

— Reprinted from Bulletin of Atlanta Envelope Co., 
Nashville, Tenn. 


FAMILY PHYSICIANS. INTERNISTS. GEN- 
ERAL PRACTITIONERS. ORTHOPEDIC 
SURGEONS, and OB-GYN needed for 
various communities throughout Tennessee. 
All opportunities are located in towns with 
a modern, fully-equipped, JCAH approved 
hospital. Contact: E. J. Ryan. Jr.. Director- 
Medical Relations, Hospital Corporation 
of America, P.O. Box 550, Nashville, Ten- 
nessee 37203. 


Elegant Two Bedroom, Two Bath 
A partment on one of the three lead- 
ing shelling beaches in the world. 
Large screen porch overlooking the 
Gulf of Mexico. Golf and Wildlife 
Sanctuary nearby. Minimum rental 
2 weeks. 

RALPH CALL 
Dept. 15 A 
Sunset South 
Sanibel, Florida 33957 


352 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



TMA AT WORK . . • Again, January through March was one of the busiest 
periods for TMA committees, boards and councils . . . January meetings 
included a two-day session of the Board of Trustees ; a lengthy one-day 
meeting of the Committee on Continuing Medical Education; a meeting of 
the Regional Medical Program Committee, and a one-half day meeting of 
the Liaison Committee to Medical Schools . • . In February, a one-day 
Legislative Conference was sponsored and over 125 physicians throughout 
the state attended. The Conference was mainly for contact doctors and 
pertained to the TMA legislative program at the state and national level 
. . . In addition, committee meetings included the Committee on Mental 
Health; Committee on Communications and Public Service; Ad Hoc 
Committee on Abortions, and the TMA-Tennessee Hospital Association 
Liaison Committee • . . In March, a second important meeting of the 
Abortion Committee was held, and a meeting of the Committee on 
Continuing Medical Education, 

^ ^ ^ 

TMA GAINED A NET OF 91 NEW MEMBERS IN 1972 ... An increase of 91 net 
members was realized during 1972, pushing the total membership of TMA 
to 3,595. Of this number, 3,199 were also members of the AMA. This 
represents 89% of TMA's membership. 

❖ ❖ 

AMA LEADERSHIP IN PSRO . . . AMA's House of Delegates vowed the national 
organization would "provide a dominant role of leadership in the 
implementation of the PSRO program to assure that the best interest of 
the public and the profession are preserved," at their 26th Clinical 
Convention in November, 1972 in Cincinnati . . . The policy-making body 
created an Advisory Committee on Professional Standards Review 
Organizations , . . The PSRO Advisory Committee will function to assure 
input from the medical profession in the development of rules and 
regulations for PSRO’s by the U.S. Department of HEW; assist state and 
county societies in PSRO development ; and attempt to evaluate the effect 
of PSRO experiments on the quality of medical care. 

^ ^ ^ 

AMA'S MEDICREDIT PLAN . . , The Medicredit Plan, a National Health 
Insurance proposal that would provide Federal income tax credits to help 
finance the purchase of private health insurance, had 130 sponsors in 
Congress within a week after it was introduced . . . The Senate number 
of the bill is S, 444. The House number is H.R. 2222, New featuers of 
this year's bill are coverage of home health care services, dental care 
for childern, and emergency dental services for all. Coverage against 
catastrophic illness would be financed by the government for all 
citizens. 


* * 


OtiV 


OCCUPATIONAL SAFETY AND HEALTH ACT ... The Tennessee Department of 
Labor has announced that effective January 1, 1973 an employer who had 
no more than seven employees at any one time during the calendar year 
1972, will not have to comply with record and reporting requirements. 

It was explained that all employers are still required to report any 
employment accident which results in either a fatality or hospitaliza- 
tion of five or more employees. The report may be oral or written and 
must be made to the State Commissioner of Labor and the area director 
within forty-eight hours after the occurrence of such action. It was 
stated that the exemption pertains only to record keeping. All 
employers with one or more employees must comply with Federal safety and 
health standards and are still subject to safety and health inspections. 
The Tennessee Occupational Safety and Health Act applies to all 
employers with one or more employees. 

vO ^ 

^ 

MEDICAL DIRECTORY . . . All U.S. physicians will receive an AMA 
questionnaire concerning professional activities. Information from the 
questionnaires will be used in the publication of the 1973 edition of 
the AMA’s American Medical Directory . 


PHYSICIAN ASSISTANTS . . . National certification of Physician's 
Assistants by uniform examination is goal of a program launched by 
the National Board of Medical Examiners and the American Medical 
Association. AMA House of Delegates has approved the AMA Council on 
Health Manpower collaboration with the National Board of Examiners in 
developing a certification examination. 


THE CASE FOR AMERICAN MEDICINE . . . One of the outstanding speakers at 
the TMA Annual Meeting is the author of the new book "The Case for 
American Medicine: A Realistic Look at Our Health Care System." It is 

must reading for every physician and every serious student of health 
care. Author, Harry Schwartz, distinguished editorial writer for the 
New York Times, exposes scare tactics of opponents of the present 
system, shows Americans are getting more and better care than ever 
before, identifies needed improvements and how best to accomplish them, 
relates patients' complaints against socialized systems in Britain, 
Sweden and Russia, and illustrates how a U.S. government control system 
would provide less care at greater cost. The publisher is David McKay 
Company, 750 Third Avenue, New York, New York 10017. 

^ ^ 

^ 'T* -T* 

DID YOU KNOW . . . HEW reports that 2,300,000 persons each day see a 
physician. The nearest physician is only seventeen minutes from the 
average home, and 20,000,000 house calls were made in 1969, more than 
half of which were to families with annual income under $3,000, the 
elderly or the handicapped . . . The AMA will publish and circulate a 
new monthly magazine, PRISM, to deal with the socio-economic questions 
of health care and medicine . . . More than our fair share might be the 
reactions of the medical profession to the first week of Congress. Of 
the more than 2,350 pieces of legislation entered, 375 pertain to health 
care . . . One of the best ever Annual Meetings of TMA was just con- 
cluded with the 1973 meeting in Memphis. Complete details of the 
actions of the House of Delegates, and a resume of resolutions, amend- . 
ments, reports and elections, will appear in the June issue of the 
Journal. 



SURVEY CONFIRMS TMA POSITION ON MD TRAINING. . . A recent survey in 
East Tennessee shows a large percentage of young physicians establish 
their private practice in an area where they complete their medical 
training. The University of Tennessee Memorial Research Hospital in 
Knoxville trained 52 physicians (35 residents and 17 interns) during 
the survey period of 1970-72. A total of 38 of those trained are now in 
private practice, 81.5 percent of them in East Tennessee. Twelve of 
the 52 entered military service and two others are receiving additional 
training. Dr. Joseph E. Johnson, UT Vice-President for Health Affairs, 
noted that 31 of the 38 physicians entered private practice within the 
State and most of them within 100 miles of the UT Hospital where they 
completed their medical training. Fourteen of the MDs remained in 
Knoxville, two established their practice in Crossville and Kingsport 
and one each in Harrogate, Morristown, New Tazewell, Halls Cross Roads, 
Maynardville, Chattanooga, White Pine, Oak Ridge and Newport. Four 
others settled in Middle Tennessee — two in Columbia and one each in 
Dickson and Smithville. The new Clinical Education Center, which began 
operating as part of the UT Hospital, is expected to increase the 
number of physicians locating in East Tennessee. Establishment of these 
training centers, which are designed to provide the final year of pre- 
intern training for some of the medical students at UT in Memphis, is in 
keeping with the Tennessee Higher Education Commission's recommendation 
which was endorsed by TMA. Similar centers are planned for the 
Tri-Cities area as well as Chattanooga. 




MEDICREDIT LEGISLATION NOW BEFORE CONGRESS ... The American Medical 
Association's national health insurance proposal, Medicredit, has been 
reintroduced into Congress by Clifford P. Hansen (R-Wyo) and Vance 
Hartke (D-Ind) as S.444 in the Senate, and by Richard Fulton (D-Tenn) 
and Joel T. Broyhill (R-Va) as H.R. 2222 in the House of Representa- 
tives. The bill had 126 sponsors almost immediately upon introduction, 
and many more are anticipated as the session progresses. New additions 
to the bill this year are basic benefit coverage of home health 
services, dental care for children, and emergency dental services for 
all. Coverage under the program would be provided through private 


health insurance, including prepaid groups. Government would under- 
write the full cost for low-income families and 10 to 99 percent of the 
cost for others, according to need. Among Medicredit's other 
provisions are: 

• Basic benefits covering emergency and preventive care, physical 
examinations, well-baby care, inoculations. X-ray and lab work for 
both in- and outpatients ; 60 days of hospitalization or 120 days 
in an extended-care facility, during one year. 

• Catastrophic protection covering expenses beyond basic coverage, 
including hospital, extended-care facility, inpatient drugs, 
blood, prosthetic appliances and other specified services. 

• Annual |50 deductible per person for hospital stay; 20-percent 
coinsurance on medical services, emergency or outpatient expenses 
and dental services. 

• Unlimited psychiatric coverage. 


❖ ❖ 


WASHINGTON LEGISLATIVE NOTES . . . AMA’s Medicredit bill, medicine’s 
national health insurance proposal, has more sponsors in Congress than 
all other NIH proposals combined. Included as sponsors are all eight 
Tennessee Congressmen plus Senator Howard Baker. . . . AMA's Medicredit 
bill is the only national health insurance proposal, due to the tax 
credit approach, which would not be subject to Presidential impoundment. 
. • . Senator Edward Kennedy’s HMO legislation has been approved by the 
Senate Health Subcommittee and is expected to reach the Senate floor 
at any time. The bill calls for establishment of HMD’s costing $5 
billion over the next three years. The Senate adopted a similar 
Kennedy measure last session by a vote of 60-14. The Administration has 
indicated opposition along with AMA and others. ... Because of the 
Administration’s attempt to cut back and/or eliminate many health 
programs, new HEW Commissioner Caspar Weinberger has been nicknamed 
"Cap the Knife" by some Washington wags. . . . Undersecretary of HEW, 
Frank Carlucci, has announced that the three main HEW goals for this 
year with regard to Professional Standards Review Organizations are 
(1) area designations; (2) writing of the regulations, which aren’t 
expected to be completed before October, and (3) appointment of the 
eleven-member National PSRO Council. . . . The Senate Finance Committee 
is expected to form six new subcommittees including one on Health. 
Senator Russell Long (D-La) chairman of the Senate Finance Committee, is 
expected to name Senator Herman Talmadge (D-Ga) as head of the Health 
panel. Some luster could be removed from Senator Kennedy’s subcommittee 
as a result. ... 


A Short Eventful Year 



Wm. T. Satterfield 


As my tour of duty as President of the Tennessee Medical Association 
draws to a close, this is occasion for reflections. The honor of serving in 
this capacity is greatly appreciated. It is regrettable that the ball 
bounces to so few of the many qualified to serve in the position, as the 
experiences are enjoyable and unforgettable. 


|>re/idcnlV 

pcic^ 


The position offers an education in matters medical. Meetings — local 
and national, volumes of printed matter to be read, and associations 
with professional and lay leaders, contribute to a wealth of knowledge 
in all aspects of things affecting medicine. There are varieties of 
acceptability, from the cordial reception given when a guest at neighboring 
states’ medical meetings, to the cool, “hate-all-doctors” chill of 
consumer and labor health conferences. 


The most impressionable impact of the position, however, is the full 
realization of the unselfish efforts of colleagues in the Association serving 
on committees and as officers. Many valuable man hours are contributed 
for the betterment of medicine and the elevation of care of patients 
in our State. The dedication of TMA members and pride in our 
executive staff adds to the appreciation of the honor of being your 
84th President. 


My successor. Dr. Morse Kochtitzky, has served TMA for many years 
and will be one of your best Presidents. He is knowledgeable in medical 
affairs and experienced in legislative activities. I welcome him to 
the Presidency and am sure he will lead you well in a very important 
year. 

Thank you for the honor of representing you. 


Sincerely, 

President 




The New President 



MORSE KOCHTITZKY, M.D. 


Nashville 


362 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



Morse Kochtitzky, M,D, 

85th President — Tennessee Medical Association 


s AN ACTIVE LEADER in the Tennessee Medical Association for the past twenty years, the 
new President has always searched for a better way to accomplish Medicine’s goals. He is a 
physician with dedication and determination to give of himself to lead in solving some of the 
complicated problems that face Medicine. 


Dr. Kochtitzky was born in St. Louis on December 22, 1920. His early life was spent in 
Blytheville, Arkansas, and Columbus, Mississippi, where he received his early education. He 
attended the University of the South at Sewanee, with time out for service in the United States 
Air Force during World War II, where he served as a navigator and radar operator with the rank 
of Second Lieutenant. 


Following military service. Dr. Kochtitzky returned to the University of the South, after which 
he entered Vanderbilt University Medical School, where he received the MD Degree in June, 
1950. Internship and residency in Medicine was served at St. Thomas Hospital in Nashville. In 
1954, he joined with Drs. Thomas Frist and Addison Scoville in the practice of internal medicine 
at Nashville. A short training course in hematology was completed in the Jefferson-Hillman Hos- 
pital at Birmingham, Alabama. 

Dr. Kochtitzky has served his state medical association in numerous capacities. These include 
Secretary-Treasurer and member of the Board of Trustees; Chairman of TMA’s Legislative Com- 
mittee for five years; a legislative contact doctor; Chairman of the Finance Committee of the 
Board of Trustees; past Chairman of the Communications and Public Service Committee; member 
of the Medical Licensure, and Governmental Medical Services Committees. Other service includes 
three terms (nine years) on the Tennessee Public Health Council where he was elected Secretary 
of the Council. He has been active in the Middle Tennessee Heart Association, serving as Presi- 
dent and Chairman of the Board. His other activities include membership on the Board of 
Trustees and Chairman of the National Development Campaign of the University of the South, 
where he received an honorary doctoral degree. He also served the University’s alumni associa- 
tion as a national officer and president of the Nashville Chapter. 

Dr. Kochtitzky has held the position of Chairman of the Park View Hospital, and former Chief 
of Medicine at Baptist Hospital in Nashville. He and his family are members of St. George’s 
Episcopal Church, and he is Senior Warden and member of the Vestry. He is married to the 
former Miss Marjorie Stevenson of Columbus, Mississippi, and they reside on Hampton Avenue 
in Nashville. They have two children, a daughter, Catherine (Mrs. Peter) Simpson of Batavia, 
Illinois, and son, Rodney, a sophomore at the University of the South. 

The problems and pressures of Medicine today impose severe demands on medical association 
leaders. TMA’s Presidents must be dedicated to the responsibilities of their ofiice. The Tennes- 
see Medical Association continues in its good fortune to have a new President that ably provides 
these qualifications. 


APRIL, 1973 


363 


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joumcil 

OF THE 

TENNESSEE MEDICAL ASSOCIATION 
PUBLISHED MONTHLY 

DEVOTED TO THE INTERESTS OF THE MEDICAL 
PROFESSION OF TENNESSEE 

OFFICE OF PUBLICATION, 112 LOUISE AVENUE, 
NASHVILLE, TENN. 37203 

JOHN B. THOMISON, M.D., EDITOR 

ADDISON B. SCOVILLE, JR., M.D., ASSOCIATE EDITOR 


Acceptance for mailing at special rate of postage provided 
for in Section 1103, Act of October 3, 1917, 
authorized July 15, 1932. 


Copyright for protection against republication. Journals 
of the American Medical Association and of other 
state medical associations may feel free to quote 
from this Journal whenever they desire 
merely giving credit to this publication. 


Address papers, discussions and scientific matter to 
John B. Thomison, M.D., Editor, P.O. Box 70, 
Nashville, fenn. 37202 

Address organizational matters to Jack E. Ballentine, 
Executive Dir., 112 Louise Avenue, Nashville, Tenn. 37203. 

COMMITTEE ON SCIENTIFIC AFFAIRS 
HARRY A. STONE, M.D., Chairman, Chattanooga 
R. L. DeSAUSSURE, M.D., Memphis 
JOHN H. BURKHART, M.D., Knoxville 
HARRISON J. SHULL, M.D., Nashville 
CHARLES E. ALLEN, M.D., Johnson City 
JOHN B. THOMISON, M.D., Nashville 


APRIL, 1973 


ccPitoriftl/ 

EASTER 1973 

Much of Western civilization’s greatest art is 
centered around the Passion of Our Lord, yet 
it does little actually to make real for us the 
horrors of the Roman execution and prior 
torture which he endured. In the first place, 
the artists have been generally ignorant of the 
details, and they also have sought to remain 
in the realm of the aesthetically pleasing — an 
impossible task, for there is no way to paint 
an aesthetically pleasing portrait and at the same 
time show the extent of his brutalization. The 
gospel accounts themselves are sparing of words, 
possibly because those living in the early days 
of the church had the picture in the flesh daily 
before their eyes. 

The sequence of events on that Friday nearly 
2000 years ago has intrigued not only the faith- 
ful, to whom it has great spiritual significance, 
and artists, who have found it a source of 


364 


inspiration, but also physicians and historians, 
medical and otherwise, on purely secular 
grounds. Why, for example, did Jesus’ death 
occur in a few hours, when it frequently took 
as much as 2 days? And what caused death, 
anyway? Roman procedural and combat man- 
uals have answered many of our questions. 

We must remember, first, that Jesus received 
extensive punishment before his crucifixion. 
He had been up all night, bound with thongs 
and possibly struck with staves, and had faced 
a grueling cross-examination. The words used 
in translating the gospel account fail to convey 
the true nature of his ordeal. The Roman 
soldier was a highly trained, efficient fighting 
machine. Duty in Palestine was not very highly 
regarded, and was probably boring, so that any 
exercise in brutality was a welcome relief. Where 
the gospels say simply that they “smote” him, 
we can picture bone crushing blows to the face. 
The crown of thorns was doubtless made of the 
limber boughs of a native Palestinian thorn tree, 
the thorns of which have a reverse curve, so 
that any attempt to remove it or change its 
position would extensively lacerate the flesh. 
The soldiers were using Jesus as a foil for 
their boredom. We can be sure that when the 
account says they “struck him over the head 
with a reed,” it was no love tap. 

Scourging, a customary prelude to crucifixion, 
was carried out in order to weaken the prisoner 
and hurry his death, and was delivered with a 
multi-thonged whip into which were knotted 
bits of stone, iron, bone and glass. In the hands 
of a skilled executioner it was capable of lit- 
erally stripping the flesh from the back. Though 
occasionally eyes and other areas were damaged, 
it was considered a lack of expertise to apply 
the lash to areas other than the back, and there 
is no evidence in scripture that in this case it 
was done in other than expert fashion. 

We see then a completely exhausted Jesus, 
with a flayed back, massive scalp lacerations 
and contusions, probably also with multiple 
facial lacerations and fractures of the facial 
bones, being forced to bear his cross through 
the streets of Jerusalem to the place of his 
execution. It was customary, under Roman 
law, to use the Tau cross, only the cross-beam, 
weighing about 150 pounds, being carried, or 
rather dragged, by the prisoner. This was placed 
atop the permanently fixed stake. We may, how- 
ever, deduce from the fact that a superscrip- 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


tion was nailed to the cross above his head 
that Jesus was nailed to the less commonly 
used type of cross which we associate with his 
crucifixion. The weight of the cross on his 
bleeding shoulders proved to be too much for 
him, weakened by shock and loss of blood, 
so that a bystander was impressed to bear it. 
We may assume that as he crumpled under the 
cross, he sustained further injury from its 
weight. 

Crucifixion was called by Cicero the most 
cruel and brutal form of execution imaginable, 
and yet it was designed not as a form of torture 
but as an efficient means of execution. No 
Roman citizen could be crucified; this form of 
execution was devised as an expedient to keep 
the conquered districts in line. It was a form 
of execution unknown to the Jews. It was done 
in a uniform way, according to a manual. 

The cross was usually low, being 6 feet 8 
inches in height, to facilitate terminal activities 
and removal of the body. The prisoner was 
seated on a cornu, or small saddle. The feet 
were nailed in place one over the other, with 
the knees flexed. The arms were maximally 
extended above the head at approximately a 45° 
angle, so that the saddle barely bore the pris- 
oner’s weight, and nailed to the cross-beam. 
The nail usually passed through the wrist, and 
though we are told in the gospel account 
of Jesus’ “nail-scarred hands,” the account of 
the crucifixion says simply that he was nailed 
to the cross. Again, the writers apparently as- 
sumed a prior knowledge of the details on the 
part of the reader. This has been objected to 
on grounds that the palms could not have borne 
the weight of the body. The purpose of the 
nails, however was only to keep the arms in 
position. Weight was borne by the saddle, 
otherwise death would have occurred in a few 
minutes. 

When the arms are extended above the head 
in fixed position, so that no movement of the 
thorax is possible, blood pools in the lower 
part of the body, the blood pressure drops, and 
fainting may occur. The painful tug on the 
hands served to revive the victim. If not soon 
relieved, death might supervene from heart 
failure. In addition, respiration in this position 
is virtually impossible, the muscles of respiration 
soon become paralyzed, and death might occur 
from suffocation. Both of these situations could 
be temporarily relieved by extending the lower 


extremities on the fulcrum of the nailed feet 
to bring the arms to a more or less horizontal 
position. In this manner, death could be fore- 
stalled indefinitely, subject only to the stamina 
of the prisoner and to the tender mercies of 
the guard, who had the power to end the 
torture by the simple expedient of breaking the 
legs with a club. Shock, suffocation, and heart 
failure rapidly ensued. 

The final event, to ensure death before re- 
leasing the body to relatives, was a thrust to 
the heart with a short lance, in the use of which 
the Roman soldier was extremely skilled. Be- 
cause the cross was low, a normal combat 
maneuver could be used to inflict a wound 
about 5 feet off the ground, in which the lance 
pierced the fifth interspace just to the right of 
the sternum (which in combat was at the edge 
of the opponent’s shield), tearing the right 
atrium, at the same time releasing the fluid 
which had accumulated in the pericardial and 
pleural spaces from shock and heart failure. 

“But when they came to Jesus and saw that 
he was already dead, they did not break his 
legs. But one of the soldiers pierced his side 
with a spear, and at once there came out blood 
and water. He who saw it has borne witness 
that you also may believe. For these things 
took place that the scripture might be fulfilled, 
‘not a bone of him shall be broken.’ ” 

We look at Easter past the cross to the 
empty tomb, but we overlook the cross at our 
peril, because it says something to us as phy- 
sicians, regardless of our beliefs. The world’s 
watchword today is “rights — mine!” The lesson 
of God’s Son on the cross is mostly ignored. 
We entered of our own volition, with our eyes 
open, a life dedicated to service. “I will follow 
that system of regimen which, according to 
my ability and judgment, I consider for the 
benefit of my patients. . . . With purity and 
holiness [set apart for a special purpose] I will 
pass my life and practice my Art.” Remember? 
It does not behoove any of us in our houses 
of glass to throw stones, but simply to look 
at ourselves, and on this Easter, to remember. 

J.B.T. 

“THEY” IS “US” 

Whenever I hear, as I too often do {ever 
is too often) a doctor say “I don’t belong to 
AMA because I don’t like what they do.” I 
say, “You have no right to an opinion, friend, 


APRIL, 1973 


365 


unless you belong. Then you can complain, if 
you are trying to change it.” 

This issue of the Journal carries a paper 
entitled “The Role of the County Medical So- 
ciety.” It is short and to the point. The 
reasoning of those who do not belong to their 
county society, and indeed to TMA and AMA 
as well, escapes me. I do not subscribe to 
everything any of them say, but I should not 
expect to. I did not let a few disagreements 
keep me from marriage, and my wife and I are 
still together after nearly 30 years of not in- 
frequent disagreements. Why should I expect 
more from my medical society? 

The medical news is filled these days with 
reports of physicians’ unions. These are being 
formed largely by people who have given up 
on organized medicine (I wonder if they ever 
tried it), but who recognize that in union there 
is strength. I wonder how closely they have 
looked at the legal requirements for unions. I 
refer you to the excellent and comprehensive 
report in the California Medical Association 
News, Aug. 18, 1972, reprinted in The Dela- 
ware Medical Journal for Feb. 1973, page 44; 
entitled “Special Report on Physicians Unions,” 
to which I am indebted for the information on 
unions given below. 

Unions are clearly defined by law, and op- 
erate within a very narrow framework. In order 
to belong to a union, one must be an employee. 
Unions are allowed to bargain for advantages, 
which by law when engaged in by anyone else, 
including the self-employed, is called price fix- 
ing, which is illegal, and falls under the Sher- 
man Anti-trust Act. It has been made clear 
that any physicians’ organization would fall 
in this category. 

The union speaks for its members, makes 
choices of policies which vitally affect him, and 
negotiates contracts which bind him. The union 
is, in short, the worker’s industrial government. 
The courts have made it quite clear that mem- 
bers are committed to abide by union policies, 
whether they agree or not. Is this what you 
would like? It would be out of the frying pan 
into the fire. 

With whom would the physicians’ union 
bargain? There is no real counterpart to labor’s 
employer, and to bargain with the government 
would only lead to further government inroads 
into the medical care field. Against whom 
would the unions strike? Against patients? The 

366 


resort to striking is clearly in conflict with basic 
professional concepts. 

In 1970, California Medical Association’s 
House of Delegates stated that “physicians 
have one major responsibility and duty; The 
provision of medical care of the highest quality 
to all persons. . . . Unionizing the medical pro- 
fession would bring with it, in addition to a 
great many other disadvantages, the important 
deterrant that we would forever forfeit our pro- 
fessional status and jeopardize the dignity of 
our profession.” 

So much for unions. What then is the an- 
swer? Strong medical societies. They cannot, 
by law, act like unions, i.e., they cannot bargain 
economically or strike or boycott. But they 
do, if we are united, hold a trump card, thusly 
summed up by a wag, “If they fire us, who 
have they got?” We can unite, and make our 
views felt in legislative bodies. This is done 
through strong medical societies. 

Are you disgruntled, depressed, pessimistic? 
Don’t just sit there. Do something — not just 
anything, but get active in your society. They 
have a job waiting for you. 

J.B.T. 

BLOOD 

You are urged to read and attend to the 
article on page 334 entitled “Red Cell (Packed 
Cell) Transfusions: An Appeal to Reason.” 

It tells why you should use packed cells rather 
than whole blood, and why whole blood is 
indeed seldom necessary, even when sizable 
quantities of whole blood are lost. The author 
points out that there are in fact times when 
whole blood is contraindicated, and its use 
could become grounds for malpractice litiga- 
tion. In light of this, should not the routine 
order for “blood” be understood as “packed 
red cells,” so that to give whole blood would 
require a special order? Some of us who auto- 
matically say to the nurse “whole blood” when 
packed cells would suffice would need to re- 
educate ourselves — or perhaps educate our- 
selves not to react negatively should the nurse 
ask in response, “Doctor, do you mean packed 
cells?” Do you. Doctor? 

J.B.T. 

MORE DRUGS AND SUCH 

We have had a good deal to say in these 
columns over the past year about prescription 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


drugs, package inserts, antisubstitution laws, the 
FDA’s relationship to all of this, and the like. 
Reprinted as a special item on page 382 of this 
issue of the Journal is a statement by James 
R. Goddard, M.D., chairman of the board of 
Ormont Drug and Chemical Co., and former 
Commissioner of the FDA, who makes some 
very penetrating statements about the issues 
surrounding the “unapproved” use of drugs, 
and proposes some answers to the problem. 

I realize that even to use the terms “ap- 
proved” or “unapproved” uses of drugs waves 
a red flag in the face of practitioners of medi- 
cine, and so you may get turned off so early 
in his statement that you won’t read it. I urge 
you to hear him through, because whether we 
like it or not, the courts are saying that there 
are unapproved uses, and they tend to go by the 
package insert, lacking better criteria. We know 
who writes them, and why. 

Dr. Goddard correctly states that only phy- 
sicians engaged in the clinical practice of medi- 
cine have the expertise necessary to decide 
what are proper uses for drugs, taking every- 
thing into consideration. It is unfortunate that 
the AMA chose this particular time to disband 
its Council on Drugs, whether or not the charge 
of bowing to political pressure has any foun- 
dation. Surely the expense of the Council was 
not excessive considering its necessity. Dr. 
Goddard proposes a panel of experts to define 
accepted uses and to advise FDA, who would 
be given powers which, though broader, would 
have a much firmer base. 

We (you) had better come to some decisions 
on this matter, and make them known. There 
are some very unpalatable alternatives. Be very 
sure that the public and the federal government 
are going to insist that drug use be regulated. 
The courts have already spoken. Medicine — 
that’s you, doctors — had better speak with a 
more unified voice than has been customary 
in the past. 

J.B.T. 



BARKER, HAROLD G., Humboldt, died March 1, 
1973, age 61. Graduate of University of Tennessee 
School of Medicine, 1934. Member of Consolidated 
Medical Assembly of West Tennessee. 


SHELTON, WILLIAM G., Dyersburg, died February 
28, 1973, age 81. Graduate of Memphis Hospital 
Medical College, 1913. Member of Northwest Acad- 
emy of Medicine. 

VALENTINE, FRED M., SR., Newport, died February 
27, 1973, age 70. Graduate of University of Ten- 
nessee School of Medicine, 1926. Member of Cocke 
County Medical Society. 


Aeiii flicfiibef/ 


The Journal takes this opportunity to welcome these 
new members of the Tennessee Medical Association. 

BLOUNT COUNTY MEDICAL SOCIETY 

Paul W. Hoffmann, M.D., Maryville 
Ronald A. Moss, M.D., Maryville 

COCKE COUNTY MEDICAL SOCIETY 

A. J. Garbarino, M.D., Newport 

CONSOLIDATED MEDICAL ASSEMBLY 
OF WEST TENNESSEE 

Delza Penaranda, M.D., Milan 

McMINN COUNTY MEDICAL SOCIETY 

George Ackaouy, M.D., Athens 

MONROE COUNTY MEDICAL SOCIETY 

James Lester Allen, M.D., Sweetwater 

NASHVILLE ACADEMY OF MEDICINE 

Erol Genca, M.D., Nashville 
Marvin G. Gregory, M.D., Nashville 
Philip J. Noel, Jr., M.D., Nashville 
William O. T. Smith, M.D., Madison 

SULLIVAN-JOHNSON COUNTY 
MEDICAL SOCIETY 

Leo J. Davis, M.D., Kingsport 
Ricardo D. Sambat, M.D., Kingsport 


pfOOfCIffl/ QACl fittui/ of 

inedicol /ocidie/ 


Knoxville Academy of Medicine 

The February 13 meeting featured Dr. Luther L. 
Terry, former Surgeon General of the U.S. Public 
Health Service speaking on “Smoking and Health: 
Where Are We Now and Where Are We Going.” 
Dr. Terry was selected to present the second annual 
James L. Southworth Memorial Lecture. 

The March 13 meeting of the Academy was de- 
voted to scientific programs in pathology, anesthesi- 
ology, surgery, ophthalmology, and radiology. 

Nashville Academy of Medicine 

The Legislative Committee hosted a dinner meet- 
ing for state Senate and House members for the Nash- 
ville area in February at the University Club. 


APRIL, 1973 


367 





Medicine’s men on the Hiii. 


Just who are they? They’re the AMA’s perma- 
nent representatives to Congress and a part of 
the AMA’s Washington staff. 

In the 92nd Congress, about 10% of all legisla- 
tion introduced was health related — more than 
2,500 bills. The AMA’s representatives serve 
as the eyes, ears and voice for our profession 
on such legislation. Keeping in close contact 
with members of Congress and their staffs. 
Explaining and promoting our profession’s 
views. Reporting on legislation. And providing 
legislators with resource material and informa- 
tion on medical and health subjects. 

They’re on the Hill to protect your interests. 


lobbying to retain the basic principles of private 
practice in any government health program that 
might be enacted. Equally important, they lobby 
to insure the passage of constructive and work- 
able health legislation for the public. 

Sure, the AMA lobbies. We lobby for the rights 
and interests of our profession and for quality 
medical care for every American. By adding 
your voice, your support, we can be even more 
effective. 

Join us. 

We can do much more together. 

American Medical Association 
535 N. Dearborn St. /Chicago, III. 60610 


The Alcoholism and Drug Abuse Committee met on 
two occasions recently and has objected to the Dis- 
trict Attorney’s proposal to ban the use of amphet- 
amines in Tennessee. 

Roane-Anderson County Medical Society 

In 1959, the society established a scholarship fund 
to give financial aid to deserving Tennessee medical 
students. The society recently reported that a total of 
$23,000 has now been contributed to medical students 
in the form of scholarships. Recipients of the schol- 
arships are selected by the respective medical school. 


iKilienol new/ 


THIS MONTH IN WASHINGTON 
(From Washington Office, AMA) 

The American Medical Association took to 
Congress its protest against retention of con- 
trols over physicians in Phase III of the Eco- 
nomic Stabilization Program. 

In a statement to the Senate Committee on 
Banking, Housing and Urban Affairs, which 
was considering a one -year extension of statu- 
tory authority for the program, the AMA cited 
the “highly discriminatory” treatment of phy- 
sicians and other health care providers under 
the program despite their cooperation and 
“laudable record of self-restraint.” 

“We have questioned the wisdom of many 
of the policies which have been initiated in 
the various regulatory phases since August of 
1971,” the AMA statement said. “In particular, 
we have objected to certain aspects because of 
the highly discriminatory treatment accorded 
health care providers. This discrimination has 
been even heightened under Phase III of the 
Administration’s program. On January 11, 
1973, mandatory wage and price controls were 
suspended for most sectors of the economy but 
were continued to be enforced upon health care 
providers. Our opposition to this discrimination 
does not stem from self-interest, nor is it based 
solely upon invidious comparison with those 
segments of the economy no longer subject to 
mandatory control. The question we raise here 
is more fundamental. It is submitted that the 
capricious imposition of controls on select 
groups only serves to frustrate the basic ob- 
jectives of the stabilization program itself. If 
regulation is to be effective, it must recognize 
the interrelationships existing within the econ- 
omy in general. Without such accomplishment 


the intent of the law will be frustrated. 

“Physicians’ fees constitute a relatively small 
percentage of the gross national product (less 
than 1.5%) and they constitute a small factor 
in the consumer price index weighting structure 
(less than 1.8%). Given the relatively slight 
impact of this factor upon the economy as a 
whole, the suspension of mandatory controls 
would not work counter to the goals of the 
Economic Stabilization Program. Conversely, 
continued controls could not be expected to 
yield meaningful restraints throughout the 
balance of the economy. The continuation of 
mandatory controls, therefore, does not appear 
to be consistent with the letter or spirit of 
the Economic Stabilization Act. 

“The Congress found in enacting the Eco- 
nomic Stabilization Act that prompt judgments 
and actions by the executive branch of the 
government were necessary to meet extreme 
economic fluctuations. The Congress, however, 
directed the President to conduct such emergen- 
cy programs in a fair and equitable manner and 
to make such adjustments as may be necessary 
to prevent gross inequities. Standards estab- 
lished under an emergency program must com- 
ply with the criteria of section 203 (b) of the 
act which provides, among other things, that 
such standards shall be “generally fair and 
equitable” and that the program must call for 
“generally comparable sacrifices by business 
and labor as well as other segments of the 
economy.” 

“We emphasize that this statutory authority 
presumes the existence of an economic emer- 
gency and authorizes a coherent and compre- 
hensive governmental response. Only a system 
of price stabilization effective at all levels of 
production and consumption and having equi- 
table incidence within the economy should be 
countenanced. To invoke controls for one 
activity without the reasonable expectation of 
achieving a result having universal application 
is to employ the statute in a punitive manner. 
Punitive treatment of health care professionals 
is neither sanctioned by law nor warranted by 
the record. 

“It is apparent from the physician component 
of the consumer price index that the medical 
community has fully complied with efforts to 
curb inflation during Phase I and II of the new 
economic policy. In the period from August 
1971 to December 1972 the all items category. 


APRIL, 1973 


369 




as measured by the consumer price index, rose 
at a rate of 4.2%, the all services component 
at the rate of 4.6%, while physicians’ fees rose 
only 3.2%. In the period from November 
1971 to December 1972 (i.e., during the 14 
months of Phase II) the all items category rose 
3.8%, the price of all services rose at a rate 
of 3.8% while physicians’ fees rose at a rate 
of 2.6%. For the calendar year 1972, phy- 
sicians’ fees increased only 2.1%. This percent- 
age is below the 2.5% annual goal set by the 
Health Services Industry Committee of the Price 
Commission, and represents a rate of increase 
of only one-third the rate of increase prior to 
Phase I. Since the goal of the Economic Stabili- 
zation Program was to halve the rate of infla- 
tion, the record achieved by physicians sur- 
passed considerably the expectations of the 

program. Thus, there is no indication that 

physicians’ fees have been a major inflationary 
factor during the course of the stabilization 
program, and it is difficult to discern any 

rationale for imposing mandatory controls in this 
sector. Continued controls do not appear to be 
the just reward for this record of compliance. 
We submit that this precedent could have a 
demoralizing effect on other industries which 
might well conclude that a record of restraint 
does not preclude imposition of a continued 
regimen of control. . . . 

“All activities require the basic factors of 
production, and all of us must compete in the 
marketplace for these necessary goods and 
services. It will become increasingly difficult 
for the health care services to obtain needed 
material and manpower unless the stabilization 
program is administered in a nondiscriminatory 
fashion.” 

The National Cancer Institute has established 
an International Tumor Immunotherapy Registry 
to serve as a center for collection, storage and 
exchange of information on immunological 
methods of treating cancer. 

The registry will record physicians’ experience 
with immunotherapy for human cancer, includ- 
ing methods of administration, results of the 
treatment, and possible side effects. It will be 
kept up-to-date by periodic progress reports 
from the physicians, who will in turn receive 
newsletters containing summaries of the most 
recent information. Computers are expected to 

370 


handle much of the work involved in maintain- 
ing the registry. 

Immunological methods of cancer treatment, 
which stimulate a patient’s immune system to 
attack cancer cells, are increasingly being eval- 
uated against types of cancer not treatable by 
other methods. Many different approaches are 
being explored, and results have been variable. 
It is hoped that the rapid communication af- 
forded by the registry will prevent needless 
duplication of unsuccessful treatment and en- 
courage cooperation in well-controlled studies 
of promising approaches. 

:H ❖ 

The American Medical Association warned 
of “possible adverse consequences” of abolish- 
ing the physician-patient privilege in federal 
court cases. 

The AMA’s “deep concern” was expressed 
in letters from Ernest B. Howard, M.D., AMA 
executive vice president, to the chairmen of the 
House and Senate judiciary committees which 
were considering such an abolition in the pro- 
posed new federal rules of evidence. 

Dr. Howard reiterated the Association’s posi- 
tion that “a qualified physician-patient relation- 
ship should be recognized.” He said that the 
pertinent rule in the American Bar Association’s 
Uniform Rules of Evidence would be preferable 
to the complete abolition of the privilege. 

The House committee was sent a copy of the 
AMA’s statement on the matter presented to 
the Advisory Committee on Federal Rules of 
Evidence, Judicial Conference of the United 
States. 

“We urge your committee to consider the ef- 
fect of the abolition of the general physician- 
patient privilege noted in our statement and the 
confusion that may become prevalent if state and 
federal courts observe different rules when con- 
sidering evidence based upon confidential com- 
munications made by a patient to his attending 
physician during the course of the physician- 
patient relationship,” Dr. Howard said. 

“The American Medical Association, as you 
will notice, does not advocate that an absolute 
or unrestricted physician-patient privilege be es- 
tablished. Acceptance of the basic concept of 
the physician-patient privilege (with limitations 
and restrictions that assure the proper adminis- 
tration of justice) is vital, however, to avoid 
abuse of individual rights and inhibition of frank 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


communication essential in the physician-patient 
relationship,” 

“The physician-patient relationship is tradi- 
tionally a confidential relationship requiring a 
high level of trust on the part of the patient. 
For proper diagnosis and treatment of a patient’s 
illness it is often essential that the patient be en- 
couraged to disclose facts, circumstances, 
opinions and attitudes concerning his personal 
or family life. Some of these disclosures are 
pertinent to the diagnosis and treatment and 
others are not. The pertinence cannot be de- 
termined until the disclosure has been made by 
the patient and evaluated by the physician. 

“Patients generally believe that what they dis- 
close to their physicians in confidence will not 
be revealed to others without the patient’s con- 
sent. Although most patients probably do not 
understand the legal concept of privileged com- 
munication, they would certainly be shocked to 
learn that their physician could be compelled, 
under penalty of contempt, to reveal in a court 
proceeding the most intimate and private in- 
formation which they have given to the phy- 
sician in reliance on this confidentiality. Ob- 
viously, not all of the information given by a 
patient to a physician has that degree of inti- 
macy and privacy which would make compulsory 
disclosure disruptive of the physician-patient 
relationship. Because of wide variations in per- 
sonal and individual sensitivity of patients, how- 
ever, it does not appear to be practical to enum- 
erate the specific kinds of information that are 
barred from disclosure. Proper concern for in- 
dividual rights would seem to dictate that, as 
far as possible, the patient should be the one 
to determine what kind of information is to be 
considered confidential and barred from com- 
pulsory disclosure. 

“It is relatively easy to identify areas of 
medical inquiry which are most likely to result 
in disclosures by a patient that should be kept 
secret. These would include sexual impotence, 
sexual sterility, venereal disease, pregnancy of 
the unwed, homosexuality, leprosy, epilepsy, 
and artificial insemination. Disclosure of per- 
sonal information in these areas would be con- 
sidered harmful and grossly embarrassing to 
most patients. Disclosures in many other areas, 
however, would be equally repugnant to some 
patients. 

“In the field of psychiatric care, especially, 
the free expression of facts, occurrences, actions. 


thoughts, feelings and dreams by the patient to 
the physician is often deemed essential for ef- 
fective diagnosis and treatment. In this field, 
compulsory disclosure of such matters would be 
most harmful to the welfare of the patient. 

“The medical profession recognizes also that 
the proper administration of justice is essential 
for the welfare of the public, including patients 
and physicians. It is aware that a rule of com- 
plete privilege, such as that applied in the 
attorney-client relationship can lead to abuses 
which result in a miscarriage of justice. If a 
patient uses a broad physician-patient privilege 
to bar disclosure of relevant information which 
would adversely affect the outcome of litigation 
of a liability claim made by him, this abuse of 
the privilege would be conducive to fraud. 

“On the other hand, fraud against a patient 
could also be perpetrated by threatening to com- 
pel his physician to disclose private and confi- 
dential information that has little if any relevancy 
to the issues raised in the litigation. The total 
abolition of the physician-patient privilege would 
leave the patient substantially without protec- 
tion against this kind of abuse. Judicial deter- 
mination of relevancy alone would not be 
sufficient protection, since some degree of dis- 
closure would be necessary to obtain the judicial 
determination. 

“We believe that justice and a true concern 
about individual rights requires that a reasonable 
balance be reached between these competing 
interests. Unrestricted physician-patient privi- 
lege has undoubtedly led to instance of mis- 
carriage of justice. Denial of any privilege, 
however, would also lead to abuse of individual 
rights and an impairment of the quality of med- 
ical care. The proper solution appears to be the 
acceptance of the basic concept of the physician- 
patient privilege with those minimum limitations 
and restrictions on the privilege as are reasonably 
necessary to assure the proper administration of 
justice.” 

The American Bar Association rule, the AMA 
said, “appears to provide reasonable limitations 
on the physician-patient privilege, sufficient to 
assure the proper administration of justice. It 
also appears to offer the patient at least a mini- 
mum degree of protection for his individual 
rights in relation to the disclosure of private and 
confidential information deemed harmful or em- 
barrassing to him. It would, at least, be less 
harmful to the quality of medical care available 


APRIL, 1973 


371 




0 • 
l 

c. 

LI 

(.■' 

ji 


to the public than a rule would be which com- 
pletely abolished the privilege.” 


cclical ncui/ 

AC 



Rudolph H. Kampmeier, M.D. 


American College of Physicians 
Announces 1973 Award Recipients 

PHILADELPHIA— Rudolph H. Kampmeier, 
M.D., was one of eight nationally prominent 
physicians who have been named recipients of 
the 1973 American College of Physicians awards 
for outstanding contributions to the progress of 
medicine and health. The College is an interna- 
tional medical specialty society representing 
more than 20,000 internists and specialists in 
related fields. 

The awards were presented Monday, April 9, 
1973, at the opening event of the American 
College of Physicians 54th Annual Session held 
at the Conrad Hilton Hotel, Chicago, 111. The 
College President, William A. Sodeman, M.D., 
Philadelphia, Pa., made the presentations. 

The Alfred Stengel Memorial Award for out- 
standing service to the American College of 
Physicians went to Dr. Kampmeier, Nashville, 


Tenn., who is Professor Emeritus, Vanderbilt 
University School of Medicine, and a Past Presi- 
dent of the American College of Physicians. 

Kampmeier Retires As Editor 
Of Southern Medical Journal 

R. H. Kampmeier, M.D., former editor of the 
TMAJ, retired as of the first of this year as 
editor of the Southern Medical Journal. The 
January issue was a “festschrift” in honor of Dr. 
Kampmeier. Tennessee physicians who con- 
tributed to the festschrift are Drs. John M. 
Flexner, Robert A. Goodwin, Roger M. Des 
Prez, Anderson Spickard, Robert H. Alford, 
Grant W. Liddle, Robert M. Carey, Janice G. 
Douglas, Philip W. Felts, Oscar B. Crofford, 
Alan L. Graber, William W. Lacy, William D. 
Salmon, Jr., William F. Meacham, Warren F. 
McPherson, John L. Sawyers, H. William Scott, 
Jr., Barton McSwain, William Whitehead, Lynch 
Bennett, Richard France, William J. Stone, 
Andrew M. Michelakis, Fred Goldner, Eric 
Engel, Fasih U. Samad, Robert C. Hartman, 
Alexander C. McLeod, James D. Snell, Jr., 
Randolph Batson and F. Tremaine Billings, Jr., 
all of Nashville, and William J. Tolleson, 
Memphis. 

Ad Hoc Abortion Committee Appointed 

TMA President Dr. William T. Satterfield, 
Sr., Memphis, has appointed a special ad hoc 
committee to study the abortion controversy in 
fight of the recent U.S. Supreme Court Ruling. 
The committee is composed of: W. Powell 

Hutcherson, M.D., Chattanooga; Stewart A. 
Fish, M.D., and Sam P. Patterson, M.D., Mem- 
phis; C. Gordon Peerman, Jr., M.D., and 
Russell T. Birmingham, M.D. of Nashville, and 
John H. Saffold, M.D. of Knoxville. 

Dr. Dial 

A new public service has been launched in 
Chattanooga which is designed to give the latest 
information on a variety of health problems to 
anyone who phones in. The program, titled 
“Dr. Dial” permits the caller to listen to a 
recorded message on a particular facet of health. 
Each tape is updated periodically in order to 
maintain current information. 


new/ 


DR. LUTHER BEAZLEY, Donelson, has been ap- 


372 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 





pointed to the Tennessee Medicaid Medical Advisory 
Committee by Governor Dunn. 

DR. J. MCDONALD BURKHART, Knoxville, and 
DR. PHILIP L. FUSON, Morristown, are participating 
in the Emergency Medical Technicians training pro- 
gram in their areas. 

DR. DAVID S. CARROLL, Memphis, has been named 
President of the Radiological Society of North America. 
DR. LOCKE CARTER, Kingsport, has been elected 
president of the medical and dental staff of the 
Holston Valley Community Hospital in Kingsport. 
DR. MAX A. CROCKER, Lexington, has accepted a 
position as associate professor of Eamily Medicine at 
the University of Kentucky School of Medicine. 

DR. WILLIAM G. CROOK, Jackson, has been named 
recipient of the 1972 Enuresis Eoundation Award. 
DR. C. HARWELL DABBS, Knoxville, has moved 
his practice to Rockwood. 

DR. ROBERT DEMOS, Chattanooga, has been ap- 
pointed chairman of the Moccasin Bend Regional Sub- 
committee of the Alcohol and Drug Advisory Com- 
mission. 

DR. HAMEL B. EASON, Memphis, has been elected 
president of Methodist Hospital medical staff succeed- 
ing DR. E. N. STEVENSON. 

DR. HAMEL B. EASON and DR. JOHN L. 
HOUSTON, both of Memphis, have been chosen 
Medical Staff Officers of the year at Methodist Hos- 
pital. 

DR. WILLIAM A. HENSLEY, Cookeville, has been 
certified as a Diplomate of the American Board of 
Family Practice. 

DR. ROBERT G. HEWGLEY, Athens, has been 
elected Chief of Staff of Epperson Hospital succeeding 
DR. BILL EOREE. 

DR. BOBBY CLARK HIGGS, Jackson, has been se- 
lected by the American Academy of Pediatrics to serve 
as a Head Start consultant in Jackson. 

DR. JOHN H. LILLARD, Athens, has assumed duties 
as assistant regional health officer of the Southeast 
regional office of the Tennessee Department of Public 
Health. 

DR. HOUSTON LOWRY, Madisonville, has been ap- 
pointed chairman of TMA’s Rural Health Committee 
succeeding DR. CHARLES TRAHERN who has 
moved his practice to Arizona. 

DR. C. BRUCE C. MARSH, Chattanooga, has received 
notification of his qualifications as a diplomate to the 
American Board of Internal Medicine. 

DR. DAVID McConnell, Newport, has been 
elected President of the Newport Chamber of Com- 
merce. 

DR. ROBERT M. MILES, Memphis, has been named 
President-Elect of the Southeastern Surgical Congress 
during the 41st annual assembly in New Orleans. 

DR. M. ERANK TURNEY, Knoxville, professor and 
chairman of University Hospital’s neurosurgical sec- 
tion, has been named president-elect of the Southern 
Neurosurgical Society. 

DR. ROBERT A. UTTERBACK, Memphis, has been 


elected President of the newly formed Memphis Acad- 
emy for Neurology. Others elected were DR. JESSE 
LAWRENCE, President-elect; and DR. HELIO 
LEMMI, Secretary-Treasurer. 


onnouncemenl/ 


CALENDAR OF MEETINGS 

STATE 


May 17 

Middle Tennessee Medical Association, 
Blue Grass Country Club, Henderson- 
ville 

NATIONAL 

April 23-28 

American Academy of Neurology, 
Sheraton-Boston Hotel, Boston 

April 25-27 

American Surgical Association, Cen- 
tury-Plaza Hotel, Los Angeles 

May 2-5 

American Gynecological Society, 
Broadmoor Hotel, Colorado Springs 

May 11-12 

American Association of Clinical 
Urologists, New York Hilton Hotel, 
New York 

May 13-17 

American Urological Association, New 
York Hilton Hotel, New York 

May 16-20 

American Pediatric Society, Hilton 
Hotel, San Francisco 

May 2 1 -24 

American College of Obstetricians and 
Gynecologists, Americana Hotel, Bal 
Harbour, Fla. 

May 21-24 

American Thoracic Society, Statler 
Hilton Hotel, New York 

June 10-14 

American Proctologic Society, Detroit 
Hilton Hotel, Detroit 

June 14-16 

American Electroencephalographic So- 
ciety, Statler Hilton, Boston 

June 16 

American College of Preventive Medi- 
cine, New York 

June 20-22 

Endocrine Society, Sheraton-Chicago 
Hotel, Chicago 

June 23-24 

American Diabetes Association, Drake 
Hotel, Chicago 

June 24-27 

American Association of Plastic Sur- 
geons, Waldorf-Astoria, New York 

June 24-28 

American Medical Association, Ameri- 
cana Hotel, New York 


CONTINUNG EDUCATION 
OPPORTUNITIES 

Meharry Medical College CME Courses 

The following continuing education courses are 
being offered by the Meharry Medical College 
during 1973: 

May 10-11 The Robert Brown Memorial Pulmo- 
nary Disease Symposium, Learning 
Resources Center, Kermit Brown, M.D. 


APRIL, 1973 


373 




May 23-24 


May 25-26 


November 3 


13th Annual Seminar in Psychiatry, 
Location to be announced, Vergil 
Metts, M.D., (Sponsored jointly with 
Vanderbilt Univ.) 

The Family Physician and the Emo- 
tionally 111 Patient, Learning Resources 
Center, Jeanne Spurlock, M.D. 
Radiation Technology, Learning Re- 
sources Center 


University of Tennessee CME Courses 

The following continuing education courses are 
being offered by the University of Tennessee College 
of Medicine during 1973: 


Date: 
May 9-11 
May 9-12 


May 14-18 
May 20-23 


Course: 

Pulmonary Disease 

Clinical Electrocardiography (Paris 
Landing State Park Inn, Buchanan, 
Tennessee) 

Intensive Review of the Science of 
Anesthesiology 

Basic Principles of Rhinoplasty 


Vanderbilt University CME Courses 


Date 

April 27-28 

May 23-24 

July 11-12 
Sept. 19-21 

Sept. 26-28 

Oct. 10-12 
Oct. 25-27 


Title, Location, Program Cordinator 
Pros and Cons of Group Practice, 
(Organization Alternatives in Medical 
Practice) University Club of Nash- 
ville, Paul Slaton, M.D. 

13th Annual Seminar in Psychiatry, 
Location to be announced, Vergil 
Metts, M.D. 

Kentucky Medical Association, An- 
nual Meeting, Lake Barkley, Kentucky 
Endocrinology (American College of 
Physicians) Underwood Auditorium, 
Vanderbilt, Grant W. Liddle, M.D. 
The Injured Child (American Academy 
of Orthopedic Surgeons) Underwood 
Auditorium, Vanderbilt, John Con- 
nolly, M.D. 

Hypertension (American College of 
Cardiology) Underwood Auditorium, 
Vanderbilt, Lawrence Grossman, M.D. 
Child Neurology, Underwood Audi- 
torium, Vanderbilt, Gerald Fenichel, 
M.D. 


University of Kentucky College of Medicine 

Date Title, Location, Program Cordinator 

April 30- Cardiac Diagnosis and Treatment, 

May 1 U. K. Medical Center, Borys Surawicz, 

M.D. 


May 2-4 Symposium on Pediatric Radiology, 

University of Kentucky, Frank R. 
Lemon, M.D. 

May 24-25 Annual Pediatric Review, U.K. Medical 
Center, Nancy Holland, M.D. 


1973 POSTGRADUATE COURSES 


These courses are arranged through the cooperation 
of the directors and the institutions involved. Regis- 
tration forms and requests for information are to be 
directed to: Registrar, Postgraduate Courses, Ameri- 

can College of Physicians, 4200 Pine Street, Phila- 
delphia, Pa. 19104. Tuition Fees: ACP Members and 
Fellows, $80; Non-Members, $125; Associates, $40; 
Other Residents and Research Fellows, $80. 

Date Title and Location 


Apr. 24-27 
Apr. 25-27 
Apr. 25-27 

May 16-18 

May 16-18 
May 21-25 

May 21-25 

May 29- 
June 1 

June 4-8 

June 13-15 

June 18-22 

June 25-29 


PULMONARY DISEASE, University of 
Pennsylvania School of Medicine, Phila- 
delphia, Pa. 

HEPATOBILIARY DISEASE IN CLIN- 
ICAL PRACTICE, University of Cali- 
fornia, San Francisco 
ADVANCES IN DIAGNOSIS AND 
MANAGEMENT OF INFECTIOUS 
DISEASE, University of Wisconsin, 
Madison, Wis. 

THE RHEUMATIC DISEASES— 
CLINICAL AND IMMUNOLOGICAL 
ASPECTS, University of Texas South- 
western Medical School, Dallas, Texas 
CLINICAL AUSCULTATION OF THE 
HEART, Georgetown University Hos- 
pital, Washington, D.C. 

INTERNAL MEDICINE: CURRENT 
CONCEPTS OF CLINICAL PROB- 
LEMS, University of Cincinnati Medical 
Center, Cincinnati, Ohio 
INTENSIVE CARE UNITS, St. Vin- 
cent’s Hospital and Medical Center of 
New York, New York, N.Y. 

RECENT ADVANCES IN ENDO- 
CRINOLOGY AND THEIR CLINICAL 
APPLICATIONS, Royal Victoria Hos- 
pital, Montreal, Que., Canada 
HEMATOLOGY, University of Wash- 
ington School of Medicine, Seattle, 
Washington 

ONCOLOGY AND CHEMOTHER- 
APY, University of Southern California, 
Los Angeles, California 
CLINICAL ASPECTS OF BLOOD 
TRANSFUSION, Michigan State Uni- 
versity, East Lansing, Mich. 
ADVANCES IN INTERNAL MEDI- 
CINE: RECENT PERSPECTIVES, 

1973, Banff, Alta, Canada 


Master Interpretation of 
Clinical Electrophysiology 

The University of Miami School of Medicine and 
the Council on Clinical Cardiology of the American 
Heart Association will present a postgraduate semi- 
nar entitled: “Master Interpretation of Clinical Elec- 
trophysiology” on May 29-31, 1973. The program 
will be held at the Contemporary Hotel at Disney 
World, Lake Buena Vista, Florida. 


374 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Tuition for the course is $150 nonmembers; $125 
Fellows and members of the Council on Clinical 
Cardiology, and Physicians in training. Registration 
is limited to 150. 

Inquiries should be addressed to Dr. Louis Lem- 
berg, University of Miami School of Medicine, P.O. 
Box 875, Biscayne Annex, Miami, Florida 33152. 

American Board of Family Practice 
Sets Certification Exam Date 

The American Board of Family Practice will give 
its next two-day written certification examination on 
October 20-21, 1973, in various centers geographically 
distributed throughout the United States. Information 
regarding the examination can be obtained by writing 
Nicholas J. Pisacano, M.D., Secretary, American 
Board of Family Practice, Inc., University of Ken- 
tucky Medical Center, Annex #2, Room 229, Lex- 
ington, Kentucky 40506. 

It is necessary for each physician desiring to take 
the examination to file a completed application with 
the Board office. Deadline for receipt of applications 
at the Board office is August 1, 1973. 

National Congress on Medical Ethics 

The Fourth National Congress on Medical Ethics 
will be held April 26, 27, 28, 1973, Washington Hilton, 
Washington, D.C. 

Among the subjects to be discussed will be; “What 
is Medical Ethics”; “How Does the Student or the 
Resident or the Nurse See Medical Ethics”; “The 
Teaching of Medical Ethics”; “Medical Ethics and 
the New Biology,” etc. There will also be a skit 
entitled “Grand Rounds on Medical Ethics.” 

Symposium on Pediatric Radiology 

This three-day symposium to be held May 2-4, 1973 
will deal with many practical problems in the diag- 
nosis of abdominal, chest, and skeletal disease in 
childhood. A distinguished guest and University of 
Kentucky faculty will join in presenting the conference, 
organized to meet the need of practicing pediatricians 
and radiologists. 

Direct inquiries to: Frank R. Lemon, M.D., Con- 
tinuing Education, College of Medicine, University of 
Kentucky, Lexington, Kentucky 40506. 

National Health Council 
Offers Short Courses 

The National Health Council, through its Commit- 
tee on Continuing Education announces ten short 
courses in 1973 selected for personnel of official, pro- 
fessional, and voluntary health agencies and organiza- 
tions. 

The course subjects will include: Comprehensive 

Health Planning, Consultation Skills, Community Or- 
ganization in Health Care Services, Executive Develop- 
ment, Leadership Development, and Voluntary Health 
Agency in the Community. 

The ten courses will be conducted by seven univer- 
sities on various dates ranging from April through 


August 1973. Cooperating universities are: Columbia 
University (School of Public Health), University of 
Florida (College of Health Related Professions), 
George Williams College (Division of Social Work 
Education), Indiana University (Graduate School of 
Business), University of Michigan (School of Public 
Health), University of Oklahoma (Department of 
Health Administration and School of Health), and 
Washington University (Office of Conferences and 
Short Courses). 

Descriptive brochures and other information on 
these courses may be obtained by writing to: Con- 

tinuing Education Program, National Health Council, 
1740 Broadway, New York, New York 10019. 

Medical Group Practice Organization 
Plans Southeast Regional Meeting 

The Lewis-Gale Clinic, Inc. of Salem, Virginia, will 
host the Southeast Regional Meeting of the American 
Association of Medical Clinics Eriday and Saturday 
May 4 and 5 at the Sheraton Motor Inn in Roanoke. 
The two-day session, covering various phases of the 
group practice of medicine, will be open to all group 
practice physicians and administrators in the Region, 
which includes Tennessee. 

The American Association of Medical Clinics is the 
national association representing all forms of medical 
group practice and group practice physicians. 

Eurther information or registration details may be 
obtained by contacting the Program Chairman: 

Warren L. Moorman, M.D. 

Lewis-Gale Clinic, Inc. 

1802 Braeburn Drive 
Salem, Virginia 24153 

Institute for Sex Research Summer 
Program in Human Sexuality 
July 8-19 

Lecture course, forums on socio-sexual issues, sex 
counseling symposia, attitude-reassessment program, 
informal workshops. $325 includes housing. Registra- 
tion ends June 18. 

Write: Institute for Sex Research 
416 Morrison Hall 
Indiana University 
Bloomington, Indiana 47401 

The American College of 
Obstetricians and Gynecologists 

The Annual Clinical Meeting of American College 
of Obstetricians and Gynecologists will be held May 
21-24, Americana Hotel, Bal Harbour, Ela. New this 
year are postgraduate courses throughout the meeting 
as well as preceding it, and informal Curbstone Con- 
sultations with two authorities on each subject. There 
will be new Self-Assessment Tests in Clinical Obstetrics 
and Clinical Gynecology. Registration fee for non- 
members, $125. 

Contact: Donald E. Richardson, Associate Director, 
American College of Obstetricians and Gynecologists, 
One East Wacker Drive, Chicago, 111. 60601. 


APRIL, 1973 


375 


Southern OB-GYN Seminar 

The 19th Annual Ob-Gyn Seminar will be held 
again this year in Asheville, North Carolina at the 
Grove Park Inn, July 22 through July 27. Broad 
aspects and subjects in obstetrics and gynecology will 
be presented. 

For registration information please contact the Sec- 
retary, Dr. George T. Schneider, 1514 Jefferson High- 
way, New Orleans, Louisiana 70121. 

Tennessee Heart Association 
Annual Meeting 

The Scientific Session of the twentieth Annual Meet- 
ing of the Tennessee Heart Association is scheduled for 
May 17 through May 19 at the Regency Hyatt House 
in Knoxville. 

Frank London, M.D., president of THA, says an 
excellent program is planned with visiting lecturers 
discussing: The Clinical Evaluation of Chest Pain, The 
Selection of Patients for Coronary Surgery: Radio- 

logic-Pathologic Correlation, Surgery of the Coronary 
Circulation, Post-operative Evaluation of Surgically- 
treated Coronary Artery Disease, Approach to Neonate 
with Heart Disease, Congenital Heart Disease in the 
Adult, Natural History of Common Congenital Cardiac 


Defects with Consideration to Surgical Intervention. 

Edward Buonocore, M.D., president of East Tennes- 
see Heart Association, will conduct a Diagnostic X-ray 
Conference of Heart Disease. 

The guest faculty features J. Willis Hurst, immediate 
past president of American Heart Association. Dr. 
Hurst is professor and chairman of the Department of 
Medicine, Emory University School of Medicine, and 
Chief of Medicine at Grady Memorial Hospital. 

Other faculty include Alexander S. Nadas, M.D., 
professor of Pediatrics at Children’s Hospital, Harvard 
Medical School; Melvin P. Judkins, M.D., professor 
and chairman. Department of Radiology, Loma Linda 
University; David C. Sabiston, Jr., M.D., professor 
and chairman of the Department of Surgery, Duke 
University Medical Center. 

James J. Acker, M.D., and J. E. Acker, Jr., M.D., 
of the University of Tennessee Research Center and 
Hospital in Knoxville, are co-chairmen for the session 
which will be accredited for 15 elective hours by the 
American Academy of General Practice and the Ten- 
nessee Medical Association. 

Eor information regarding registration contact James 
C. Arnold, Executive Director, Tennessee Heart As- 
sociation, 205-22nd Avenue, North, Nashville, Tennes- 
see 37203. 


20th Scientific Session and Annual Meeting 16th General Assembly 


TENNESSEE HEART ASSOCIATION 

MAY 17-19, 1973 -REGENCY HYATT HOUSE -KNOXVILLE 



Thursday, May 17 

Friday, May 18 

Saturday, May 19 

Morning 

Scientific Session 
Film Festival 

M.D.’s Tour of U.T. 
Hospital Clinical 

Presentation — J. 
Willis Hurst, M.D. 
CPR Demonstration 
Film Festival 

Awards Breakfast 
General Assembly 

Afternoon 

Scientific Session 
Non-Medical Session 
—“What You Al- 
ways Wanted to 
Know — But Were 
Afraid to Ask” 

Joint Medical & Non- 
Medical Session 
Panel Sessions 



SPECIAL EVENTS FOR THE LADIES 

Knoxville Historical Tour 
Blount Mansion & Craighead Jackson House 
Pigeon Forge &, Gatlinburg 
West Town Shopping Mall 


SCIENTIFIC SESSION 

Co-sponsor — East Tennessee 
ijHeart Association 
features 

j. WILLIS HURST, M.D. 

Past President, American Heart Association 

VISITING LECTURERS WILL 
DISCUSS: 

The Clinical Evaluation of Chest Pain 
The Selection of Patients for Coronary 
Surgery; Radiologic-Pathologic Correia- j 
tion 

Surgery of the Coronary Circulation | 

Post-operative Evaluation of Surgically- 
treated Coronary Artery Disease 
Approach to Neonate with Heart Disease 
Congenital Heart Disease in the Adult 
Natural History of Common Congenital 
Cardiac Defects with Consideration to i 
Surgical Intervention 

Diagnostic X-ray Conference of Heart ; 
Disease i 


376 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



Man sa^ 
from attack but 
increased blood 
pressure in 
hemorrhoidal 


standinq 

Man sa^ 


veins 


:aution 

longed or excessive 
of Anusol-HC might 
duce systemic 
icosteroid effects, 
iptomatic relief should 
delay definitive 
[nosis or treatment, 
iage and Administration 
isol-HC; One suppository 
le morning and one at 
time for 3 to 6 days 
ntil the inflammation 
sides. 

'ular Anusol: one 
pository in the morning, 
at bedtime, and one 
lediately following each 
:uation. 


to help ease 
acute symptoms of 
hemorrhoids 


Anusd-HC 


Hemorrhoidal Suppositories with Hydrocortisone Acetate. On your Rx only! 

Each suppository contains hydrocortisone acetate 10 mg; bismuth subgallate 2.25%; 
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Warner/GMicott 



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cocr Anusol 

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Tffl 



/pcciol 
ilcm 



James L. Goddard, M.D., Former FDA 
Commissioner, Statement to Senate 
Subcommittee on Health 

Mr. Chairman, I am James L. Goodard, 
M.D., chairman of the board of Ormont Drug 
& Chemical Company, Englewood, N.J. In re- 
cent years, the attention of those interested in 
the field of pharmaceuticals has been directed on 
several occasions to the issues surrounding the 
“unapproved” use of marketed drugs or chem- 
icals. On several occasions. Congressional com- 
mittees have raised the issue during hearings 
on related matters, but this is to my knowledge, 
the first hearing devoted solely to the subject. 

The issue is a complex one — with ramifica- 
tions relating to the quality of patient care, the 
role of the federal agency vis-a-vis the medical 
profession, the responsibilities of the phara- 
maceutical firms involved, and the legal liabil- 
ities of physicians who use marketed drugs for 
unlabeled uses. In the short time available to 
me I cannot cover all aspects of this important 
subject and I will therefore limit my remarks to 
the issues of the effect on patient care and what 
steps can be taken which may improve the 
situation. 

With respect to patient care, my concerns are 
related to the potential dangers that may arise as 
a result of using marketed drugs for unlabeled 
uses. There is the danger that incomplete in- 
formation will denigrate the quality of care. 
Ordinarily, the physician has rather compre- 
hensive information available to him from a 
variety of sources: 

a. the professional literature 

b. the package circular 

c. Physicians Desk Reference 

d. AMA handbook of drugs 

e. promotional material from manufacturers. 

When marketed drugs are used for unlabeled 

uses, it is apparent that existing information will 
not be directly applicable and that the profes- 
sional literature becomes the sole source of 
printed information. This could be sufficient 
were it not for the fact that much of the “un- 
approved” use is based on word of mouth 
“testimonials” rather than careful study of ma- 
terial presented in a journal. An equally sig- 


nificant drawback is that usage is often based 
on a single uncorroborated study rather than 
a number of well controlled studies. 

This means that the physician really is unable 
to judge comprehensive efficacy; have any sig- 
nificant knowledge as to side effects which might 
be unique in relation to the “unlabeled” indica- 
tion; that drug interactions can occur and as a 
result patient care would suffer. 

I concede all of these may not occur and 
the patient may indeed benefit — as I also con- 
cede the attending physician must be one to 
make the ultimate judgment as to which medica- 
tion for which condition. 

What then can or should be done? I would 
suggest the following: 

1. By FDA 

a. Under existing authority very little could 
be done. FDA should not get involved in super- 
vising medical practice. The problem would be 
lessened if FDA were more responsive to well 
documented studies demonstrating effectiveness 
for new uses. 

b. Under new authority, FDA could formally 

provide the manufacturer with the opportunity 
to assume the burden of proof and if dechned 
by the manufacturer holding the NDA, then any 
other manufacturer will do so: with proviso 

that a license must be issued by the first com- 
pany and that royalties be paid; or special 
clinical pharmacology centers underwritten by 
FDA grants could; after review by NAS-NRC 
be asked to undertake study of efficacy. Follow- 
ing this — the drug would be available for manu- 
facture by any company willing to pay royalties 
to the originating firm. 

2. By Medical Profession 

a. In hospital — drug utilization committees 
to evaluate drug usage by physicians practicing 
within the hospital. 

b. In community — drug utilization review by 
Medicare-Medicaid organizations or by new 
mechanisms — e.g. one new mechanism would be 
available at such time that time sharing com- 
puters are widely utilized by M.D.’s in their 
office practice. Such a system is feasible today, 
and at a realistic cost but has not been imple- 
mented in any commodity. Many other benefits 
would become readily available which would 
be potentially of greater significance than moni- 
toring drug usage. 

3. By State Agencies 

It would not be practical under existing or 


382 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


new authorities for state agencies to be involved 
directly related to this issue. 

Overriding all that I have said is the urgent 
need for a significant change in the FDA new 
drug approval process. This is in no way criti- 
cism of the efforts of the FDA personnel who 
must operate under existing legislative mandates 
but rather a plea for substantial change in the 
law. 

Specifically, I would propose that the Con- 
gress direct the agency to establish in each 
recognized specialty, a scientific council com- 
prised of non-governmental experts who would: 

a. At the receipt of an Investigational New 
Drugs review the application to determine 
worthwhileness of the proposed study of com- 
petence of the proposed investors 

b. Maintain surveillance over the IND 
throughout each phase periodically evaluating 
progress 

c. Recommend to the commissioner ap- 
proval or disapproval at completion of Phase 
III and recommend amendments to original 
NDA’s when new indications for use have 
been developed. 

Such councils would have permanent secre- 
tariat assigned by FDA and would be of suf- 
ficient size, but the progress would not be unduly 
burdensome to any individual member. Further 
there should be provided a special mechanism 
for appeal from an adverse action on the part of 
the commissioner. 1 would suggest that a select 
group from the NAS-NRC be available for such 
appeals and that this step be required prior to 
institution of any adversary procedure through 
our federal courts. 

1 am well aware of the fears such a proposal 
could arouse in the various interested parties. 

a. The manufacturers might well express con- 
cern with regard to “trade secrets.” I would 
suggest that manufacturing processes which 
are the only trade secrets of significance in- 
volved be separated and provided to FDA as 
they now are. 

b. Consumers groups might express concern 
that undue pressure would be brought to bear 
on the scientific councils by drug manufac- 
turers. I would suggest that the broad scale 
participation by scientists of high repute along 
with periodic change of membership, provide 
a large measure of protection. 


c. Congress might fear this would be an un- 
wise delegation of responsibility. I would 
maintain it to be a highly necessary one, for 
government service can no longer attract and 
maintain an adequate body of scientific man- 
power. Such an approach would help assure 
critical evaluation of our nation’s drugs by 
those most competent to make such judg- 
ments — practitioners and scientists involved 
in the care of patients and the study of drugs 
who are deemed by their peers to be the lead- 
ing experts in their chosen fields. 

There are many subtleties of such a proposal 
which are not suitable for presentation at this 
time. I do feel however that the “problems” of 
“unlabeled use” of a marketed drug could be 
more readily solved by this approach and at the 
same time we could enjoy the benefits of earlier 
approval of NDA’s without any sacrifice of pub- 
lic safety. 


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Knoxville, Tennessee 
Phone 546-3701 


APRIL, 1973 


383 





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AMA Legislative Department — A 
Vital Service 


The American Medical Association’s Legisla- 
tive Department provides a vital service to mem- 
ber physicians all across the country. At the 
same time, it is regarded by many as one of the 
most substantial of the intangible benefits which 
the AMA offers to its membership. 

The Legislative Department staffs the AMA 
Council on Legislation and specializes in all 
phases of national legislation. After studying, 
analyzing, and interpreting all Congressional 
legislation pertaining to medical and health care, 
the department makes available this information 
to state, county, and specialty medical societies, 
members of the public, and other organizations. 
This usually totals about 2,300 bills of medical 
interest per Congress. An increased responsi- 
bility of this department is the critical review of 
government regulations which often seriously af- 
fect application of law. There are few physicians 
who could devote the time necessary to accom- 
plish this on their own and, yet, this information 
is vital because it affects the way medicine is 
practiced in this country. 

To keep key medical leadership aware of 
legislative developments when Congress is in 
session, the department writes, publishes, and 
distributes LEGISLATIVE ROUND-UP, week- 
ly, to approximately 5,000 key state, county, 
and specialty medical society officers. 

Another vital activity is the assistance given 
to AMA Officers in the preparation of testimony 
and presentations for Congressional hearings. 
The Legislative Department works with the ap- 
propriate AMA scientific personnel to gain the 
benefit of their expertise before assembling any 
presentation. The Council on Legislation can 
then use this resource material to formulate a 
sound recommendation as to the best policy 
position for the AMA. Many people do not real- 
ize the AMA is often requested to testify be- 
cause its views are valued not only by Congress 
but by the various governmental agencies. 

The department also assists in the develop- 
ment, writing, and presentation of draft legisla- 
tion for consideration by members of Congress, 
such as the AMA’s own national health insur- 


ance bill, MEDICREDIT. They also assist in 
the development of presentations to the regula- 
tory agencies. 

The staff participates in providing legislative 
orientation to the AMA’s Councils and Commit- 
tees as well as to members of the profession who 
are in Washington, D.C. to visit members of 
Congress. 

Finally, the department has undertaken the 
monitoring of state legislation with a view 
towards eventually assisting the profession to at- 
tain its legislative goals on a state as well as on a 
national level. 

From Medicaid and Medicare regulations to 
chiropractic issues, national health insurance and 
appropriations for HEW programs, federal and 
state medical and health care legislation affects 
all physicians in some way. The AMA’s Legis- 
lative Department maintains constant surveil- 
lance and provides AMA physician policy 
makers with accurate and up-to-date informa- 
tion. The leadership of organized medicine can 
make their judgments and represent AMA’s 
membership with a sound base of resources. 

AMA Legislative Dept. 


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APRIL, 1973 


385 


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specialists hereafter Indicated: Cardiologists (including cathe- 
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Otolaryngologists — No Plastic Surgery, Surgeons — General 
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386 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



The lesions on his face may 
be solar/actinic — so-called 
‘senile” keratoses... and 
they may be premalignant. 


Solar, actinic or senile keratoses 

These lesions may be called by several names, but they 
usually can be identified by the following character- 
istics: the typical lesion is flat or slightly elevated, of a 
brownish or reddish color, papular, dry, rough, adherent, 
and sharply defined. They commonly occur as multiple 
lesions, chiefly on the exposed portions of the skin. 



Patient P.T* seen on 3129167 shows typical lesions of 
moderately severe keratoses. Note residual scarring on 
ridge of nose from previous cryosurgical and electro- 
surgical procedures. 

Sequence of therapy/ 
selectivity of response 

After several days of therapy with Efudex® (fluorouracil), 
erythema may begin to appear in the area of the lesions; 
the reaction usually reaches its height of unsightliness 
and discomfort within two weeks, declining after dis- 
continuation of therapy. This reaction occurs in affected 
areas. Since the response is so predictable, lesions that 
do not respond should be biopsied. 

Acceptable results 

Treatment with Efudex provides highly favorable cos- 
metic results. Incidence of scarring is low. This is 
particularly important with multiple facial lesions. 
Efudex should be applied with care near the eyes, nose 
and mouth. 



Patient P.T.* seen on 6112167, seven weeks after discon- 
tinuation of 5%-FU cream. Reaction has subsided. 
Residual scarring not seen except for that due to prior 
surgery. Inflammation has cleared and face is clear of 
keratotic lesions. 


Before prescribing, please consult complete 
product information, a summary of which 
follows: 

Indications: Multiple actinic or solar keratoses. 
Contraindications: Patients with known hyper- 
sensitivity to any of its components. 

Warnings: If occlusive dressing used, may in- 
crease inflammatory reactions in adjacent normal 
skin. Avoid prolonged exposure to ultraviolet 
rays. Safe use in pregnancy not established. 
Precautions: If applied with fingers, wash hands 
immediately. Apply with care near eyes, nose and 
mouth. Lesions failing to respond or recurring 
should be biopsied. 

Adverse Reactions: Local — pain, pruritus, hyper- 
pigmentation and burning at application site 
most frequent; also dermatitis, scarring, soreness 
and tenderness. Also reported — insomnia, stoma- 
titis, suppuration, scaling, swelling, irritability, 
medicinal taste, photosensitivity, lacrimation, 
leukocytosis, thrombocytopenia, toxic granula- 
tion and eosinophilia. 

Dosage and Administration: Apply sufficient 
quantity to cover lesion twice daily w'ith non- 
metal applicator or suitable glove. Usual dura- 
tion of therapy is 2 to 4 weeks. 

How Supplied: Solution, 10-ml drop dispensers 
— containing 2% or 5% fluorouracil on a weight/ 
weight basis, compounded with propylene glycol, 
tris(hydroxymethyl)aminomethane, hydroxypropyl 
cellulose, parabens (methyl and propyl) and 
disodium edetate. 

Cream, 25-Gm tubes — containing 5% fluoroura- 
cil in a vanishing cream base consisting of white 
petrolatum, stearyl alcohol, propylene glycol, 
polysorbate 60 and parabens (methyl and propyl). 

This patient’s lesions 
were resolved with 

Efudex^ 

(fluorouracil) 

5% cream /solution 
...a Roche exclusive 

/ \ Roche Laboratories 

ROCHE ✓ Division of Hoffmann-La Roche Inc. 
s. / Nutley, N.J, 07110 


‘Data on file, Hoflfmann-La Roche Inc., Nutley, N.J. 



Answers to the Cooper Quiz 
(from pages 342-343) 

THE NEW ENGLAND JOURNAL OF MEDICINE 
October 5, 1972 

1. True. “Clearly, the results in the patients with 
cardiomyopathy are entirely consistent with their 
clinical status — advanced myocardial failure. By 
contrasty the measurements in the alcoholic patients 
were not in keeping with their clincal status. Al- 
though less marked than in the cardiomyopathy 
group, measurements except blood pressures dif- 
fered significantly from those of the matched nor- 
mal control patients. Moreover, all differences in 
the ‘normal’ alcoholic patients were in the same 
direction — that of ventricular malfunction — as 
those in the cardiomyopathy group. Since the 
ambulatory patients with chronic alcoholism were 
selected because they have no symptoms or signs 
and no electrocardiographic or roentgenographic 
abnormalities indicating heart disease, the results 
suggest that they already have cardiac malfunction 
and may be on their way to alcoholic heart dis- 
ease.” (p. 679) 

EDITOR’S NOTE: Much more sophisticated 

studies than we have mentioned were done, all 
indicating depressed myocardial function. 

2. True. “The causative role of surfactant deficiency 
in the production of pulmonary disease remains to 
be established. Scarpelli concludes that ‘there is no 
disease, including the respiratory distress syndrome, 
in which a primary defect of the surfactant system 
has been demonstrated conclusively as the 
etiological factor,’ an opinion shared by Clements. 
It seems, then, that with the possible exception of 
the premature infant, surfactant deficiency is a 
result, not a cause of alveolar damage. However, 
once surfactant deficiency has developed, the con- 
sequences in terms of lung function are serious.” 
(p. 694) 

3. True. “Infections with Entameba histolytica in 
this country are primarily asymptomatic in the 
form of the intestinal carrier state. Amebic dysen- 
tery and extraintestinal localization such as liver 
abscess occur relatively infrequently. On rare occa- 
sions severe and even fatal infections may be 
encountered among inhabitants of mental institu- 
tions and military personnel and after travel in 
highly endemic areas in which presumably ex- 
tremely virulent strains may occur.” (p. 701) 

October 12, 1972 

4. True. “The metabolic effects of L-dopa were 
studied in 23 patients with Parkinsonism. Levels 
of plasma growth hormone were elevated two 
hours after administration of 0.5 to 1.0 g of 
L-dopa, and this response persisted for at least 
one year. Plasma glucose was increased at two 
hours, and free fatty acids at four hours. Chronic 
therapy significantly increased serum cholesterol 
(approximately 10 percent), but no change in 


serum triglycerides, thyroxine, fasting blood sugar, 
and 24-hour urinary excretion of 17-keto and 17- 
ketogenic steroids was observed. After one year 
of chronic L-dopa therapy, there was a decrease 
in glucose tolerance associated with a delayed 
and exaggerated insulin response. The changes in 
growth hormone and carbohydrate tolerance sug- 
gest that patients receiving L-dopa for long periods 
should be monitored for the possible development 
of frank acromegaly.” (p. 729 — Abstract) 

5. 30% “Death from heatstroke is not uncommon. 
Casualties occur both in the military and in 
civilian practice particularly among athletes, labor- 
ers, and alcoholics. Reported mortality rates range 
from 17 to 70 percent, being related to the magni- 
tude of the the/mal stress and the age of the 
patient. Acute circulatory failure has been ob- 
served to precede death in more than 80 percent 
of the cases. The physiologic alterations of heat 
stress have been studied, but the mechanism of 
cardiovascular collapse during heatstroke has 

not been established definitively in man 

Prom our clinical observations the heatstroke 
victim’s circulatory pattern resembles in many 
respects the well defined low peripheral vascular 
resistance and high circulatory demand of other 
conditions involving tissue injury such as trauma 
or sepsis.” (p. 734) 

6. True. “It becomes apparent that treatment of 
heatstroke depends on two principal considera- 
tions, the first of which is that the stress and injury 
imposed by hyperthermia should be removed by 
restoration of the body temperature to normal as 
rapidly as possible. Experience has demonstrated 
that this goal can be most effectively accomplished 
by immersion of the body in an ice bath. The 
administration of pheothiazine as recommended 
by Hoagland and the use of sponging are both 
slow to reduce body temperature. The second, 
and of equal importance, is support of the cardio- 
vascular system to enable it to meet the large 
circulatory demand that occurs during hyper- 
thermia and afterward. Any reduction in circu- 
lating plasma volume secondary to previous loss of 
body fluid by evaporation should be replaced by 
Ringer’s lactate solution administered intrave- 
nously. The average volume used during the first 
four hours in this group of patients was moderate, 
approximately 1200 ml. Peripheral vascular pool- 
ing does not appear to be a major factor. Since 
central venous pressure ordinarily is high under 
these conditions, knowledge of this value would 
be helpful only when it is below 5 cm of water, 
probably indicating an inadequate filling pressure 
in the right side of the heart and the need for 
greater blood volume. Because of the initial low 
urine output and the possibility that tubular flow 
would be reduced owing to renal vasoconstriction 
and the secondary development of lower-nephron 
nephrosis, osmotic diuresis was induced by man- 
nitol administration; 12.5 g of mannitol was given 
as a bolus initially and was supplemented by an 


394 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


additional dose of 12.5 g per liter of intravenous 
fluid. Finally, heart failure, as indicated by ele- 
vated CVP and evidence of inadequate cardiac 
output, requires treatment directed toward improve- 
ment of myocardial contraction. Therapy of this 
type is particularly important in the elderly or in 
others in whom a previously insufficient myocar- 
dium may not respond adequately to the elevated 
circulatory demand of heatstroke. Digitalis has 
been recommended in the past. Beta-adrenergic 
stimulation of the myocardium by an agent such 
as isoproterenol proved effective in the hypotensive 
patient. The use of alpha-adrenergic substance 
such as norepinephrine appears illogical since it 
would promote peripheral vascular vasoconstric- 
tion without actually improving perfusion or in- 
creasing cardiac output. In addition, such vaso- 
contriction might prevent continuing skin heat 
exchange and cause further ischemic damage of 
organs such as the kidney or liver.” (p. 736) 

7. True. “Although psoriasis is an inherited dis- 
order, transmitted in a fashion most consistent 
with multifactorial models of inheritance, no ge- 
netic markers have yet been found in association 
with this disease. Russell, Schultes, and Kuban 
first noted an increased frequency of HL-A13 in 
psoriatic patients. The present study is an inde- 
pendent survey on another series of patients in 
an effort to confirm their initial observation. In 
addition to the finding of the same high frequency 
of HL-A13, the overall degree of disturbance in 
frequencies of HL-A antigens was greater than in 
any disease thus far reported.” (p. 740) 

8. True. “The demonstration of CMV infection of 
the genital tract in an asymptomatic male indi- 
cates that this virus may be transmitted by ve- 
nereal contact. The more frequent recovery of 
CMV from the cervix of younger and primiparous 
women than from multiparous women over 25 
years of age may correlate more directly with 
sexual activity than with changing endocrine fac- 
tors as has been suggested. 

“The amounts of infectious CMV found in 
semen in the present case are considerably higher 
than are found in other postnatally acquired in- 
fections. The persistence of extraordinarily high 
titers of CMV for weeks in the face of circulating 
antibody indicates that in the reproductive tract, 
as in the urine and blood, this virus may evade 
humoral defenses and can remain a protracted 
hazard. 

“The clinical features of the present case were 
not unusual. The patient had no evidence of im- 
munologic dysfunction. Heterophil-antibody-nega- 
tive mononucleosis is frequently caused by CMV 
infection, and this illness is common among young 
adults. It seems possible that the presence of CMV 
in semen also is not unusual.” (p. 758) 

October 19, 1972 

9. True. “Examination of the etiologic precursors 
of CHF as it occurs in the general population. 


undistorted by the selective bias of hospital- 
admission practices or varying criteria, reveals 
hypertension to be the salient feature before failure 
in 75 percent of the victims of myocardial de- 
compensation. CHF, as defined, was an extremely 
lethal process; 60 percent of the men and 40 per- 
cent of the women died within five years of onset. 
This is an average annual death rate about seven 
times that of persons without CHF. An appalling 
prognosis was noted for this group of predomi- 
nantly hypertensive patients with CHF, even if 
those with established coexisting coronary heart 
disease are excluded. As many as 20 percent of 
the men and 14 percent of the women died within 
a year of diagnosis. 

“It is clear that a prophylactic approach is 
indicated and that the key to this is the early, 
vigorous and sustained control of hypertension. 

“Elevated blood pressure, whether predomi- 
nantly systolic or diastolic, in either sex, at any 
age, deserves attention.” (p. 785) 

10. True. “Despite advances in nutrition and sani- 
tation, infantile diarrhea remains a major prob- 
lem in the United States. At the Cook County 
Pediatric Hospital, we admit approximately 1000 
children each year for dehydrating diarrhea. Sev- 
eral thousand other children are treated in the 
outpatient clinic. Gordon has pointed out that 
the mortality from acute diarrhea has progressively 
declined in the United States over the past 70 
years. There has also been a decreased incidence 
and a change in the seasonal prevalence: formerly 
termed ‘summer diarrhea,’ the disease now has its 
highest incidence in the winter. 

“Many micro-organisms have been associated 
with acute diarrhea. Among the bacteria these 
include salmonella, shigella, enteropathogenic 
Escherichia coli (EPEC) and vibrios. Protozoa 
such as ameba and giardia and enteroviruses can 
also cause the acute symptoms. With this imposing 
list, it is surprising that a specific pathogen cannot 
be identified in as many as 80 percent of cases 
of acute diarrhea. The laboratory usually signs 
out the stool specimen as ‘normal flora.’” (p. 791) 

JAMA 

October 2, 1972 

11. Pause. ‘’In April, 1971 we published a paper 
describing 38 cases showing the clinical effects of 
marihuana on adolescents and young adults. With 
continued clinical investigation, we have seen an 
increasing number of symptomatic cases among 
preadolescents, adolescents, and young and older 
adults that have confirmed our original impres- 
sions and at the same time have led us to an 
increasing clinical conviction that there is a spe- 
cific pathological organic response in the central 
nervous system (CNS) to cannabis products. This 
specific response was identified by a group of uni- 
form symptoms common to all which seem un- 
related to individual psychological predisposition. 
As we previously described, symptoms varied from 


APRIL, 1973 


395 


mild ego decompensation to psychotic states. We 
also considered that clinical findings resulting 
from chronic cannabis use were suggestive of a 
temporary toxic cerebral state on a biochemical 
basis. In a recent study, Campbell, et al have 
demonstrated cerebral atrophy by air enchepha- 
lography in ten individuals who had smoked 
marihuana from three to eleven years. The radio- 
logical report parallels another one of our clinical 
impressions that cerebral structural changes may 
have Occurred in some instances of intense chronic- 
cannabis use.” (p. 35) 

EDITOR’S NOTE: The toxic effects disappeared 
within 3 to 24 months after cessation of drug use. 

12. Ealse. “Human rabies resulting from bites of the 
spotted {Spilogale putorius) or striped (Mephitis 
mephitis) skunk has occurred sporadically in the 
United States since at least 1826. Epidemics of 
human rabies in Kansas in the period 1866 to 
1876 and in Arizona in the period 1907 to 1910 
were associated with epizootics of skunk rabies. 
In the past two decades rabies has become epi- 
zootic in skunks again, and skunk-associated hu- 
man rabies is once more a problem in the United 
States and in Canada.” (p. 44) 

13. 23% “Of 2,334 medical patients surveyed from 
1967 to 1968, 22.9% had received digitalis and 
21.4% of digitalis courses resulted in intoxication. 
Risk factors included old age, impaired renal 
function, myocardial infarction, severe congestive 
heart failure, cor pulmonale, excessive doses based 
on body weight, and loading courses. An educa- 
tional program in digitalis use with dosage guide- 
lines for digoxin was established. In a repeat 
survey in 1969 to 1970, only 12.3% of 578 digitalis 
courses resulted in intoxication. The number of 
loading courses and the total amount of drug 
administered as a load were reduced. Fewer 
patients received a daily maintenance dose of 
digoxin greater than 2.5^g/lb. Deaths in intoxi- 
cated patients decreased. These results indicate 
that an educational program in digitalis use based 
on clinical pharmacological principles is a valuable 
addition to medical education.” (p. 50 — Abstract) 

14. False. “A common, and often perplexing, diag- 
nostic challenge is the unfortunate person with 
recurrent abdominal pain. When a searching 
history, thorough physical examination, laboratory 
evaluation, and radiological studies are to no avail, 
such patients are often labeled neurotic, or advised 
to undergo exploratory surgery. It is in such a 
setting that the subject of abdominal epilepsy is 
occasionally raised. Since in our experience phy- 
sicians know little about this rare entity, we feel 
a brief review is pertinent at this time. 

“Experimental studies in both animal and hu- 
man subjects have shown that stimulation of cer- 
tain areas in the brain stem, hypothalamus, and 
cerebral cortex can inffuence gastrointestinal ac- 
tivity and cause a variety of visceral sensations. 
Up to 20% of patients with convulsive disorders, 
particularly those with temporal lobe seizures, will 


experience a visceral aura such as epigastric dis- 
tress, peculiar ‘rising sensations,’ nausea, vomiting, 
salivation, and borborygmi. Usually these symp- 
toms are the aura heralding the occurrence of a 
major motor seizure. On occasion, however, these 
visceral symptoms may be the only sign of par- 
oxysmal disturbance of cerebral electrical activity 
and, as such, have been labeled as convulsive 
equivalent states. An example of this is abdominal 
epilepsy.” (p. 65) 

October 9, 1972 

15. True. “Five infants, all less than 1 year of 
age, were killed by children 8 years old or younger. 
All five died from craniocerebral trauma resulting 
from assaults with a blunt instrument, being 
dropped to the floor, or both. Two had been 
bitten by their juvenile attackers. None of the 
victims showed any stigmata of adult ‘battering’ 
in the form of multiple, nonlethal metasynchronous 
trauma, and adult involvement in the fatal terminal 
episode was excluded by thorough police investi- 
gation. The delicacy of the soft and bony struc- 
tures of the infant’s head renders it vulnerable to 
mortal trauma at the hands of tiny assailants. The 
preschool child is capable of homicidal rage when 
he is provoked by what he considers to be a 
threat to his sense of social security in his family 
unit or immediate human environment.” (p. 159 — 
Abstract) 

16. “The criteria for acceptability of cadaveric 

organs for homotransplantation have been altered 
and amended as clinical experience has accumu- 
lated. Original cadaver donors were persons dying 
suddenly from variable causes but usually under 
controlled situations such as during surgical op- 
erations. The inherent danger of transmitting 
occult pathological conditions from donor to re- 
cipient, however, necessitated a more discrimi- 
nating evaluation of donors. Prompted by this. 
Couch, et al outlined principles for the use of 
cadaver tissues. He proposed that the following 
conditions would be basic contraindications for 
organ donation: (1) general bacterial sepsis, 

(2) positive serological reaction, (3) carrier status, 
such as infectious hepatitis, (4) disseminated 
cancer, (5) generalized atherosclerosis, (6) pro- 
found or prolonged shock, and (7) clinical or 
laboratory data indicating disease of the organ in 
question.” (p. 164) 

17. True. “The potential of certain drugs to cause 
a syndrome resembling systemic lupus erythema- 
tosus requires that all physicians be cognizant of 
this complication. Hydralazine, procainamide, 
isoniazid, and certain anticonvulsants are the major 
offenders. This report documents a case of drug- 
induced lupus erythematosus in which pericardial 
tamponade was life-threatening. 

“Drugs that cause lupus-like syndromes do so 
with different propensities. Alarcon-Segovia be- 
lieves that procainamide is the strongest of lupus 
inducers.” (p. 191) 


396 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


October 16, 1972 

18. False. “Hidradenitis suppurativa, is a chronic, 
progressive disease of young people that creates 
serious morbidity. Recurrent painful nodules, ab- 
scesses, and in the chronic stage, hypertrophic 
scar tissue, draining sinuses, and contractures re- 
sult in marked interference with employment and 
normal social activities. The disease is more ap- 
propriately called ‘apocrinitis’ since it involves the 
apocrine sweat glands of the axilla, groin, and 
perineum. All modes of therapy short of total 
excision of the apocrine-gland-bearing tissue is 
temporizing. Early recognition and excision of all 
involved glands will save patients the pain and 
social stigmata of this disease, and permit repair 
by relatively simple means.” (p. 320) 

19. False. “Since weight reduction, the cornerstone 
of treatment in type IV hyperlipo-proteinemia, has 
poor patient acceptance, clofibrate (2 gm/day) 
was evaluated in a double-blind study prior to 
dietary therapy in 12 patients. Mean plasma 
triglyceride levels fell with clofibrate (429 mg/ 
100 ml to 255 mg/100 ml) but not with placebo 
(565 mg/ 100 ml). In most patients, cholesterol 
levels were unchanged. Although clofibrate alone 
may be effective in certain type IV patients if both 
cholesterol and triglyceride levels are substantially 
reduced, it is no substitute for adequate dietary 
therapy.” (p. 316 — Abstract) 

October 30, 1972 

20. 1. Women; 2. Men. “The value of anticoagulant 
therapy after acute myocardial infarction has been 
assessed in 1,136 patients admitted to the Bronx 
Municipal Hospital Center. The treatment reduced 
the overall mortality in women from 31% to 15%, 
particularly those 55 years of age or over, with 
moderately severe infarction. 

“The low overall mortality in control men 
(16%) was not reduced with treatment, though 
there was significant reduction of the mortality in 
a subgroup of men with moderately severe 

infarction showing Q-wave evolution. 

“Age and sex, as well as the severity of the 

episode of acute myocardial infarction, are im- 

portant in determining whether anticoagulant 
therapy is likely to be beneficial.” (p. 541 — 
Abstract) 

EDITOR’S NOTE: As you know, this study is 
different in its findings than any we can recall 
seeing recently. 

ANNALS OF INTERNAL MEDICINE 
October, 1972 

21. True. “The experience of adult patients ad- 

mitted to a general hospital with the diagnosis 
of acute pulmonary edema was determined for 
the year before and the year after the opening 
of an intensive care unit. Comparisons made 
included hospital mortality, duration of hospital- 
ization, and total hospital charges. Mortality was 
identical in both groups (8%) and was consistent 
with the overall hospital mortality for patients 


admitted with this diagnosis during the preceding 
4 years. The duration of hospitalization was 2.3 
days longer, and the average hospital bill was 46% 
greater for patients admitted during the year after 
than for those admitted the year before the open- 
ing of an intensive care unit. The data suggest 
that the only significant change in the experience 
of patients hospitalized with acute pulmonary 
edema since the opening of a unit has been a 
marked increase in the cost of rendering care to 
these patients.” (p. 501) 

EDITOR’S NOTE: This was from the Depart- 

ment of Medicine, Strong Memorial Hospital and 
the Rochester School of Medicine and Dentistry. 

22. False. “Pleural effusions are classically divided 
into ‘transudates’ and ‘exudates’. A transudate 
occurs when the mechanical factors influencing 
the formation or reabsorption of pleural fluid are 
altered. Increased plasma osmotic pressure or 
elevated systemic or pulmonary hydrostatic pres- 
sure are alterations that produce transudates. The 
pleural surfaces are thought not to be involved 
by the primary pathologic process. In contrast, an 
exudate results from inflammation or other disease 
of the pleural surface, such as occurs in tubercu- 
losis, pneumonia with effusion, malignancy, pan- 
creatitis, pulmonary infarction, or systemic lupus 
erythematosus.” (p. 507) 

23. False. “A pleural-fluid protein level of 3.0 g/ 
100 ml is frequently used to separate transudates 
from exudates; however, this dividing line has 
consistently led to the misclassification of many 
effusions. Carr and Power found that 8% of 
their exudates and 15% of their transudates were 
misclassified by this criterion. Recently, Chan- 
drasekhar and colleagues have proposed that the 
absolute level of the pleural-fluid lactic dehy- 
drogenase (LDH) can separate transudates from 
exudates more effectively than the pleural-fluid 
protein level.” (p. 507) 

24. Exudate. “In the evaluation of a pleural effusion, 
its classification as either a transudate or an 
exudate is the first diagnostic step. If an exudative 
effusion is present, further diagnostic procedures 
are imperative, such as cytopathology, pleural 
biopsy, and sometimes even thoracotomy, so that 
a definitive diagnosis can be made and specific 
therapy for the pleural disease may be instituted. 
On the other hand, if the fluid is clearly a 
transudate, one need not worry about therapeutic 
maneuvers directed at the pleura and need treat 
only the congestive heart failure, nephrosis, cir- 
rhosis, or hypoproteinemia.” (p. 509) 

EDITOR’S NOTE: If you are interested in LDH 
separation of transudates and exudates, we feel 
you should read the entire paper. It begins on 
page 507. 

25. True. “Mitochondrial antibody was detected in 
the serum in 84% of 188 patients with primary 
biliary cirrhosis, 11% of 77 with chronic active 
hepatitis, 6% of 33 with cryptogenic cirrhosis, 


APRIL, 1973 


397 


and 0.8% of 1,328 with other diseases involving 
liver, biliary tract, or collagen but in none of 332 
with acute or chronic viral hepatitis.” (p. 533) 

26. False. “The test for mitochondrial antibody 
proved to be a remarkably accurate method for 
confirming the diagnosis of primary biliary cir- 
rhosis. Although the test was positive in 20 (1%) 
of our 1,508 patients with other disease, it led to 
few diagnostic errors. 

“Tests for mitochondrial antibody were par- 
ticularly helpful in establishing the diagnosis of 
primary biliary cirrhosis in patients with typical 
or consistent biopsy findings but with atypical 
clinical or laboratory features, such as the absence 
of pruritus, hypercholesterolemia, or both. It is 
noteworthy that the incidence of mitochondrial 
antibody in such cases was as high as that in 
patients with typical features.” (p. 540) 

27. True. “Thyroid hormone treatment for pa- 
tients with myxedema coma has generally been 
unsatisfactory, resulting in a high mortality rate. 
This is partially owing to the difficulty of making 
controlled prospective observations on the meta- 
bolic responses to the administration of various 
doses of thyroid hormone in such critically ill 
patients.” (p. 549) 

28. Lower. “The commonest and most consistent 
effect of thiazide diuretics on calcium metabolism 
is a sustained fall in urinary calcium excretion. 
During the first few days of treatment, sodium 
and water depletion result in concentration of 
plasma proteins and a rise in protein-bound and 
total plasma calcium, but values corrected for 
protein usually show no change. In a few pa- 
tients there is a genuine rise in plasma calcium, 
unrelated to plasma protein changes. This has 
resulted in most cases in worsening of preexisting 
hypercalcemia, especially in primary hyperpara- 
thyroidism. Thiazide challenge has been proposed 
as a diagnostic test in patients with borderline 
plasma calcium values in whom primary hyper- 
parathyroidism is suspected, but the need for and 
value of such a test are still uncertain.” (p. 557) 

29. False. “It is clear that thiazide diuretic adminis- 
tration can lead to hypercalcemia in hypoparathy- 
roid patients treated with vitamin D. A significant 
rise in plasma calcium levels occurred in six of 
seven patients given a thiazide experimentally, and 
hypercalcemic levels were reached in three; this 
report adds another five cases of hypercalcemia 
in patients treated with a thiazide. The results 
are especially significant because in this series, in 
contrast to all others reported, hypercalcemia has 
occurred rarely, and its cause has always been 
identified. 

“This effect of thiazide treatment seems to be 
unrelated to dose, since the patients in the experi- 


mental group were given four tablets daily (2.0 g 
of chlorothiazide or 20 mg of methyclothiazide) 
and those in the therapeutic group only one tablet 
daily (5.0 mg of bendrofluazide or methyclothi- 
azide). In one patient included in both groups 
the plasma calcium level rose more with the lower 
dose than with the higher. 

“Some patients appear to need less vitamin D 
after recovery from an episode of vitamin D 
intoxication because previous overdosage was un- 
recognized. In Case 8 there would still have been 
substantial body stores of vitamin D at the time 
that bendrofluazide was given but, even so, the 
dose of vitamin D restarted 2 weeks earlier was 
too small to have any effect on the plasma calcium 
level. The patient was confined to bed, but hyper- 
calcemia had not occurred during many previous 
hospital admissions, when only mercurial diuretics 
were given.” (p. 581) 

30. True. “The nephrotic syndrome, with morpho- 
logic features of normal or near-normal glomeruli 
by light microscopy but showing a lack of immune 
deposits along the glomerular basement membrane 
(GBM) by immunofluorescent and electron mi- 
croscopy, is a well-recognized clinical entity that 
has been variously termed ‘lipoid nephrosis,’ ‘nil 
lesion,’ ‘idiopathic,’ or ‘minimal change’ nephrotic 
syndrome. Although most patients with this entity 
respond to adrenal steroid therapy with cessation 
of proteinuria, some do not. The urine of these 
patients with ‘steroid-resistant nephrotic syndrome’ 
never becomes protein-free, and progression of this 
disease to renal failure has been recorded.” (p. 
581) 

31. Increase. “Nine normal subjects were given 50 mg 
of hydrochlorothiazide twice daily for 25 days, 
to investigate the relationships between circulating 
immunoreactive parathyroid hormone (iPTH) and 
changes in calcium homeostasis induced by this 
diuretic. Total and ionized plasma calcium con- 
centrations were significantly increased during ad- 
ministration of hydrochlorothiazide and for at least 
2 weeks after withdrawal of the drug. There was 
no clearly definable effect either on protein bind- 
ing of calcium or on iPTH. The normal negative 
correlation between ionized calcium and iPTH 
appeared to remain intact, and the mechanism 
of the increase in serum calcium is yet to be 
elucidated.” (p. 587) 

32. True. “Toxic systemic extracardiac effects of 
quinidine that have thus far been recognized in- 
clude fever, nausea, vomiting, diarrhea, abdominal 
cramps, tinnitus, deafness, headache, diplopia, hy- 
potension, colored vision, and purpura. A toxic 
effect of quinidine on the liver which was ob- 
served in a patient under treatment for ventric- 
ular premature contractions, is described.” (p. 
595) 


JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 



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1. Primary eunuchoidism and eunuchism. 2. Male 
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lished as such, and it is not just a familial trait. 

In the female: 1. Prevention of postpartum breast 
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males. Pregnancy. 

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joumcil 

OF THE 

TENNESSEE MEDICAL 
ASSOCIATION 

MAY, 1973 

Vol. 66 No. 5 

Published Monthly By 
Tennessee Medical Association 
Office of Publication, 
112 Louise Avenue 
Nashville, Tenn. 37203 

Second Class Postage Paid at 
Nashville, Tenn. 

TMA OFFICERS 

President 
O. Morse Kochtitzky, M.D. 
2104 West End Ave. 
Nashville 37203 
President-Elect 
E. Kent Carter, M.D. 
Holston Valley Community Hospital 
Kingsport 37660 
Chairman, Board of Trustees 
C. Gordon Peerman, Jr., M.D. 
21st & Hayes Medical Bldg. 

Nashville 37203 

EDITORIAL STAFF 
Editor 

John B. Thomison, M.D. 
Managing Editor and 
Business Manager 
Jack E. Ballentine 

TMA EXECUTIVE STAFF 

Executive Director 

Jack E. Ballentine 
Assistant Executive Director 
L. Hadley Williams 
Executive Assistant 
John M. Westenberger 
Executive Assistant 
William V. Wallace 
Executive Assistant 
for Legislation 
John R. Coles 

The Journal of the Tennessee 
Medical Association 
112 Louise Ave. 
Nashville, Tennessee 37203 

Published monthly under the direction of 
the Board of Trustees for and by members 
of The Tennessee Medical Association, a 
nonprofit organization, with a definite 
membership for scientific and educational 

purposes. 

Subscription $9.00 per year to non- 
members; single copy, 75 cents. Payment 
of Tennessee Medical Association 
membership dues includes the subscription 
price of this Journal. 
Devoted to the interests of the medical 
profession of Tennessee. This association 
does not officially endorse opinions 
presented in different papers published 
herein. Copyright, 1973 by the Journal of 
the Tennessee Medical Association. 
Advertisers must conform to policies and 
regulations established by the Board of 
Trustees of the 
Tennessee Medical Association, 


conlcAl/ 

SCIENTIFIC SECTION 

425 The Intensive Care Nursery: Past, Present and Future, Henry S. 
Christian, M.D., Thomas E. Lester, M.D. and Alex Ruth, M.D. 

429 Treatment of Uncomplicated Gonorrhea, Frank L. Roberts, M.D., Dr. 
P.H. 

432 A Report from the Tennessee Cancer Registry, Charles C. Trabue, 
IV, M.D. 

435 Medical Staffs Merge — Improve Quality, Reduce Costs, William M. M. 
Robinson, M.D. 

440 Laboratory Medicine 

442 EKG of the Month 

443 X-Ray of the Month 

445 Topics in Nuclear Medicine 

447 From the Tennessee Department of Public Health 
449 From the Tennessee Department of Mental Health 
453 From the Regional Medical Programs 

NEWS AND ORGANIZATIONAL SECTION 
4G5 President’s Page 
466 Editorials 

468 In Memoriam 

469 New Members 

469 Programs and News of Medical Societies 

469 National News 

472 Medical News in Tennessee 

472 Personal News 

473 Announcements 
475 Special Item 
484 The Viewing Box 

501 Placement Service 

502 Index to Advertisers 

Contents listed in CURRENT CONTENTS/CLINICAL PRACTICE 
of The Institute for Scientific Information 


INSTRUCTIONS TO CONTRIBUTORS 

Manuscripts submitted for consideration for publication in the JOURNAL 
OF THE TENNESSEE MEDICAL ASSOCIATION should be addressed to 
the Editor, John B. Thomison, M.D., P.O. Box 70, Nashville, Tennessee 
37202. 

Manuscripts must be typewritten on one side of letterweight paper. 
Either double or triple spacing and wide margins must be provided to 
facilitate editing which will be legible for the printer. The pages should 
be numbered and clipped or stapled together, but they should not be 
placed in a binder. 

Bibliographic references should not exceed twenty in number docu- 
menting key publications. They should appear at the end of the paper. 
The bibliographic references must conform to the style used in the 
American Medical Association publications, as, — Alais, FG: What is Known 
About it, J. Tennessee M. A., 35:132, 1950. 

Illustrations should be numbered and identified with the author’s name. 
The editor will determine the number, if any, of illustrations to be used 
with the Journal assuming the cost of engravings and cuts up to $25. 
Engraving cost for illustrations in excess of $25 will be billed to the 
author. They will not be returned unless specifically requested. 

If reprints are wanted, the desired number should be indicated in the 
letter accompanying the manuscript. No reprints are provided free and 
a reprint cost schedule will be forwarded upon request. 


joumol 

OF THE TENNESSEE MEDICAL ASSOCIATION 

OWNED AND PUBLISHED BY THE ASSOCIATION 

MAY, 1973 
VOLUME 66, NO. 5 


The Intensive Care Nursery: 
Past, Present & Future 

HENRY S. CHRISTIAN, M.D.,* * THOMAS E. LESTER, M.D.** AND ALEX RUTH, M.D.*** 


The Intensive Care Nursery (ICN), Univer- 
sity of Tennessee Memorial Research Center 
and Hospital, Knoxville, Tennessee has been 
in operation since August, 1970. It receives 
patients from east Tennessee, serving mainly 
the mid-east and upper-east sections. Patients 
are also referred from middle Tennessee, upper 
Georgia, upper Alabama, Kentucky, Virginia, 
and North Carolina. 

The 25 incubator intensive care unit, includ- 
ing the intermediate care area, has proved to 
be entirely too small to take care of the tre- 
mendous growth which has been experienced, 
and plans are now being formulated to expand 
to an approximate 50-bed area. The intensive 
care nursery receives only infants who are ill 
or in distress from various causes peculiar to 
the newborn, including extreme prematurity. 
The normal newborn infants, including the pre- 
matures who are not in distress, are cared for 
in another area and are not included in this 
program. 

The more common difficulties encountered 
are Respiratory Distress Syndrome, Hyaline 
Membrane Disease, Meconium Aspiration, 
Bronchopneumonia, Sepsis, Congenital Heart 
Disease, Gastrointestinal Tract Anomalies, etc. 
In the process of developing the intensive care 

tFrom the University of Tennessee Memorial Re- 
search Center & Hospital, Knoxville, Tenn. 

* Professor of Pediatrics 

** Associate Professor of Pediatrics 
::<** Assistant Professor of Pediatrics 
(Supported by grants: Appalachian Regional Com- 
mission, Grant #04-H-000417-01-0; Regional Medi- 
cal Program, Grant #8396-4967; Tennessee Tu- 

berculosis & Respiratory Disease Association; Ten- 
nessee Valley Authority). 


unit, during which time the need for such a unit 
was even more obvious than previously, it be- 
came mandatory that a system of transporting 
the infant into the ICN be developed. In the 
beginning, a Volkswagen bus was adapted to 
transport a portable isolette (Air-Shields). Two 
pediatricians from the University of Tennessee 
Memorial Research Center and Hospital made 
trips to various outlying hospitals within a radius 
of approximately 150 miles to pick up patients. 
The portable incubator supplied heat, moisture 
and oxygen to the baby in transit, guaranteeing 
that it would arrive at the ICN in the best 
possible condition. 

It very soon became apparent that this was 
not sufficient to meet the demands. Twelve 
portable isolettes (Air-Shields) were then pur- 
chased and stationed in various hospitals over 
the area. These were kept in readiness at all 
times with a full tank of oxygen in place and 
a constant temperature maintained by connect- 
ing to a wall outlet. The distressed infant was 
immediately placed in the incubator and trans- 
ported to the ICN by means of an ambulance 
from the area involved. This saved one-half of 
a round trip, thereby saving time which was 
most critical. 

Nurses, physicians, and ambulance attendants 
were trained by the ICN physicians and nursing 
staffs to care for the baby in transit. It was 
stressed that a patient would never be trans- 
ported without personnel in attendance trained 
in routine care, maintenance of adequate heat 
and oxygen, suctioning, administration of arti- 
ficial respiration, and cardiac resuscitation (thus 
far, no patient has been lost in transit or after- 
wards from faulty technique during transport). 


MAY, 1973 


425 


As the program developed, instances were 
encountered in which more rapid transport and 
transportation from less accessible areas was 
needed. Thus, helicopter transportation was ini- 
tiated, which has proven to be most efficacious 
and advantageous in certain situations. There 
are indications for the use of each of the three 
methods of transportation, and much of the 
success which the ICN has shown is attributable 
to these. 

The previously mentioned training program 
was necessary to train not only the nurses and 
ambulance attendants, but also physicians, hos- 
pital administrators, hospital personnel and the 
general public. This was done by means of 
one -day in-service training programs within the 
intensive care unit, one-day workshops, telecon- 
ferences, lectures to medical societies, nurses 
groups, professional clubs, social and service 
clubs, etc. This program was intended to por- 
tray the availability of the ICN facilities, to 
alert everyone concerning the danger signs and 
symptoms, what to look for, when to transfer, 
and what patients needed the ICN facilities. 

In order to aid the smaller hospitals and 
clinics in upgrading their equipment, techniques, 
and facilities, teams of nurses and physicians 
made visits to these areas upon request. Sug- 
gestions were offered, and at times help in pur- 
chasing equipment could be given. 

A 24-hour telephone consultation service was 
made available, which has proven most helpful. 
The telephone number of the ICN was placed 
in every nursery, clinic, hospital and physician 
office in the area, and there is always a nurse or 
physician on call who is able to answer questions 
concerning transportation, consultations, etc. 

Table I gives a statistical summary of the 
admissions since the beginning of the program in 
August 1970, as well as a summary of the 
patients during 1972 and during January 1973. 

There is a total survival rate of 78.2%. This 
includes patients with conditions incompatible 
with life — absence of kidneys, various monstros- 
ities, non-functioning heart, agenesis of the lungs, 
anencephalics, etc. The survival rate when these 
patients are excluded is 89.2%. 

The majority of the patients were admitted 
with pulmonary difficulties. Hyaline Membrane 
Disease, Atelectasis, Bronchopneumonia, etc. 
These were a total of 539 with a survival rate 
of 89.5%. 

The various methods of transportation 
426 


TABLE I 



Jan. 

Iota! 

Since 

Aug. 


’73 

1972 

’70 

Admissions 

Total 

42 

394 

853 

Deaths 

6 

80 

186 

% Survival 

85.7 

79.8 

78.2 

Incompatible 

2 

31 

94 

% Survival less Incom. 

95.0 

87.5 

89.2 

Respiratory Distress 

Total 

23 

245 

539 

Survived 

22 

207 

480 

% Survived 

95.6 

84.5 

89.5 

Congenital Heart Disease 

Total 

0 

21 

75 

Survived 


13 

50 

Operated 

0 

0 

14 

Survived 



10 

Surgical 

Total 

1 

16 

23 

Survived 

0 

14 

19 

Transported 

Total 

32 

266 

596 

U.T. Isolette 

15 

159 

All 

Local Isolette 

13 

80 

93 

Helicopter 

4 

27 

31 


brought in 596 of the 853 cases since the pro- 
gram was initiated. The incubator based at the 
University of Tennessee Memorial Research 
Center and Hospital has been responsible for 
transporting the majority of patients since it has 
been in operation the longest. The “local” in- 
cubator (those based at the outlying hospitals) 

, transported 93, and the latest mode of transpor- 
tation, the helicopter, 31. It is interesting that 
the survival rates for the transported patients 
and those born in the obstetrical department of 
the University of Tennessee Memorial Research 
Center and Hospital are identical, suggesting 
that the transport facilities are adequate and 
effective. 

The successes of the intentsive care nursery 
are gradually evolving into and becoming a part 
of a new concept — Perinatology. The field of 
Perinatology is concerned with all conditions 
surrounding birth, which includes the newly-born 
infant. In addition, it includes the prospective 
mother’s welfare even before conception, as it 
is related to pregnancy and birth, and to the 
welfare of the fetus, particularly just before and 
during delivery. The implications of this new 
concept upon intensive care of the neonate are 
tremendous, particularly as regards transport- 
ing of the patient. Obviously, the best time for 
transportation of the infant is in utero; there- 

JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


fore, it becomes necessary to transport the 
pregnant woman when difficulty is anticipated, 
so that delivery may be accomplished next door 
to the intensive care nursery. 

In the field of Perinatology, which now in- 
cludes Neonatology, there are many aspects 
which need developing, refinements to be made, 
and new avenues to be explored — just so many 
challenges. The concept of a place where care 
can be given intensively to the neonate has 
been one of the greatest recent advancements 
in the field of Pediatrics and medicine in gen- 
eral. The concept of Perinatology now opens 
up possibilities of which we could only speculate 
in the past. 

One of the greatest needs at the present time 
relates to follow-up studies. The large number 
of patients affords tremendous opportunities for 
evaluating the efforts and procedures as well as 
benefitting the patient. Repeated examinations 
at regular intervals by the pediatrician, audiolo- 
gist, ophthalmologist, psychologist, speech tech- 
nician, social worker, etc. are necessary to have 
a complete and well-rounded program. 

Since so many of the patients admitted to the 
ICN have respiratory problems, considerable 
work has been done at the University of Ten- 
nessee Memorial Research Center and Hospital 
in pulmonary physiology, particularly regarding 
the use of positive pressure, and recently nega- 
tive pressure, in the management of Hyaline 
Membrane Disease. 

Positive pressure is administered through an 
endotracheal tube, or by means of an airtight 
hood or box over the head which is tightly sealed 
about the neck. The equipment used is con- 
structed in such a manner that a constant 
pressure can be maintained at any desired level 
and a safety feature is incorporated to ensure 
that under usual conditions there is little possi- 
bility of pneumothorax. The positive pressure 
keeps the alveoli open in the absence of surfac- 
tant until the lungs can supply this phospholipid, 
which is present normally and which coats the 
inside of each alveolus, thereby keeping it in- 
flated. 

Negative pressure is administered in the same 
general manner as with the “iron lung,” which 
was used in cases of bulbar poliomyelitis. This 
can be applied either constantly, which tends to 
keep the chest in an inspiratory position, or 
intermittently which acts as a negative pressure 
respirator. The staff at the University of Ten- 


nessee Memorial Research Center and Hospital 
have become quite enthusiastic in the use of 
negative pressure because this avoids prolonged 
use of an endotracheal tube. The results are 
most encouraging and agree with those from 
other intensive care units. 

Recently the record of every patient dis- 
charged from the unit has been logged into a 
computer. All information concerning the 
patient, including history, physical examination, 
laboratory findings, diagnosis, disposition, etc. 
is entered. It is felt that this has been a most 
important addition to the ICN routine, because 
now we can evaluate our procedures, methods, 
and practices. Already we have made changes 
in the techniques because of statistical results 
supplied by the computer. 

As is always true, today’s newer methods be- 
come obsolete and are replaced tomorrow. 
There are so many areas that need to be ex- 
plored. There are many problems such as (1) 
what can be done about immaturity (baby 
weighing less than 800 gms.), (2) what can we 
do for intracranial hemorrhages and how can 
they be prevented, etc. 

There can be two methods of evaluating the 
effectiveness of an intensive care nursery: (1) 

follow-up studies to determine mental and 
physical capabilities of the individual, and (2) 
determination of the actual changes in mortality 
rates. 

The program at the University of Tennessee 
Memorial Research Center and Hospital has not 
been in operation long enough to completely 
evaluate the survivors. This will be reported 
at a later date. The studies thus far, assuming 
the patient was in good condition at the time 
of admission and not already damaged by 
anoxia, traumatic delivery, grossly subnormal 
temperatures, etc., indicate that the individual 
can be expected to be normal. 

It is a simple matter to assess the program 
by examination of neonatal mortality rates. 
Table II reveals a comparison of the rate in 
infants born in the obstetrical department of 
the University of Tennessee Memorial Research 
Center and Hospital for a two year period, July 
1965 to June 1967, with the rate of infants born 
during the first year the intensive care unit was 
in operation, August 1, 1970 to July 31, 1971. 
The neonatal mortality was decreased from 21 
to 8.8 per thousand. Table III shows the mor- 
tality rates for Knox County as compiled by the 


MAY, 1973 


427 


TABLE II 


ever, in 1971 there is a significant decrease to 
7.8 and 12.0 respectively. 

CONCLUSION; The concept of intensive 
care for the neonate is relatively new and has 
been widely accepted. The impact upon the 
neonatal mortality rate has been tremendous. 
We are now having the lowest rates in the 
history of our country. There seems little doubt 
that the incidence of cerebral palsy, brain 
damage, and other results of insufficient oxygen 
to tissues will be greatly reduced. This means 
that rather than an individual becoming a burden 
and economic drain upon society, he will be an 
economically productive tax paying citizen. The 
need for early recognition of the neonate in 
distress and early institution of therapeutic 
measures, either in the newborn nursery or in 
the intensive care nursery, cannot be stressed 
too much. The intensive care nursery is an 
expensive venture if it is to be successful. The 
cost of adequately trained personnel and the 
necessary equipment prohibit every hospital 
from supporting an intensive care unit. This 
means that the ICN is to be found in the larger 
medical centers and must afford care for larger 
areas and regions. 

^ ^ ^ 


SAINT 

ALBANS 

PSYCHIATRIC HOSPITAL 

Radford, Virginia 


STAFF: 

James P. King, M.D. 

William D. Keck, M.D. 

Morgan E. Scott, M.D. 

David S. Sprague, M.D. 

Edward E. Cale, M.D. 

Delano W. Bolter, M.D. 

Terkild 

Vinding, M.D. 

Clinical Psychology: 
Thomas C. Camp, Ph.D. 
Carl McGraw, Ph.D. 

Don Phillips, Administrator 

George K. White 
Asst. Administrator 


428 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 


Neonatal Neonatal 
Total Deaths Mortality Rate 

Date Deliveries U.T.M.R.C.H. U.T.M.R.C.H. 

July, 1965- 

June, 1967 2040 41 2.1 % 

(21 per 1000) 

Aug. I. 1970- 

July 31, 1971 1688 15 0.88% 

(8.8 per 1000) 




TABLE 

III 







1967 

1968 

Age Group 



No. 

Rate 

No. 

Rate 

Under 28 days 



60 

13.7 

71 

16.9 

Total deaths 







under 1 year 



85 

19.4 

94 

22.3 


1969 

1970 

1971 

Age Group 

No. 

Rate 

No. 

Rate 

No. 

Rate 

Under 28 days 

60 

13.2 

59 

12.9 

36 

7.8 

Total deaths 







under 1 year 

84 

18.4 

80 

17.5 

55 

12.0 


Knox County Health Department for the years 
1967 through 1971. There is a slight decrease 
in 1970 in both the neonatal and infant mortality 
rates (ICN only in operation 5 months); how- 


Treatment of Uneomplieated Gonorrhea 
By Use of Two Grams of Ampicillin and 

Two Grams of Probenecid 

FRANK L. ROBERTS, M.D., DR. P.H.* 


There has never been a great biography of 
gonorrhea. Typhus fever, yellow fever, cholera 
and smallpox have had their biographies but not 
the humble gonococcus. Gonorrhea is not a 
dramatic disease — its habitat is unmentionable, 
it is a disreputable disease and until relatively 
recently was associated with whores, whore- 
mongers and generally disreputable companions. 
It was associated with poverty and ignorance 
and although it infected many wealthy and 
“upper class” persons of both sexes its presence 
in the latter group was vigorously denied. 

However, as of now gonorrhea is no longer 
“publicly unspeakable and medically outcast 
limping through the years a veritable nobody’s 
child” (Pelouse). Gonorrhea is no longer a 
“No, no” word. It is freely used in bars and 
salons — by the poor and by the rich — it is 
everybodys’ child. 

In its quiet unassuming way, gonorrhea has 
plodded through the centuries, still misnamed as 
a flow of seed and doing untold damage. It has 
infected millions; it has blinded and crippled un- 
told thousands. It is not a dramatic disease. 
It does not rage through countries and cities 
slaying thousands; it has aroused no panic in 
the hearts of citizens. In fact, it has been re- 
ferred to contemptously as “no worse than a 
bad cold.” 

There are several truths about gonorrhea, 
some of which have been forgotten by the older 
generation of physicians and some never thought 
o